Polite Dissent

This PSA comes from various April 1965 issues of DC comics and asks what you would do if you saw a hit and run driver.

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

A good question, but sadly DC left off the part of the story where Ed and Joe are found shot execution style in the back of an alley. Or maybe that’s the Ed Brubaker version of this PSA.
The John Ostrander version would feature the injured man — or his wife — swearing vengeance and hunting down the hit and run driver.

The Chris Claremont version would be full of dialogue and tie into the previous six years worth of PSAs.

The Geoff Johns version would feature the return of an obscure Silver Age character — and lots of dismemberments and decapitations.

Judd Winick would somehow manage to fit a lecture about tolerance into the PSA, before killing off a female character.

Mark Millar’s version would consist mainly of set pieces with a slight amount of exposition and plot in between.

Brian Bendis’s version would take at least sixteen pages. “Ed” “Yeah?” “Hey, Ed” “Yeah what, Joe?” “Didja – didja see that?” “The car?” “Yeah, the car” “What about it?” “Did it-” “Yeah, it did” “You sure?” “Yeah.” By the time they finished their conversation, the victim would be dead and the driver across the state line.

And of course, there’s the Kevin Smith version, which would end abruptly after 2 panels with the rest of the page left blank.

As always, the PSA (the original version) was written by Jack Schiff. Art is by frequent PSA collaborator Sheldon Moldoff.

Tags: comics psa jack schiff sheldon moldoff

A fun episode of House this week, and let me start by breathing a sigh of relief and realizing that medical school and residency could have been a lot worse, particularly if I had applied to work with House. Spoilers follow!

There was not all that much actual medicine in this episode because most of the time was spent on interpersonal issues between House and his multitude of job applicants, and between the applicants themselves. This was actually the best part of the show, though several of the applicants reminded me a little too much of some of my less-than-fondly-remembered medical school classmates.

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Greta is an Air Force captain who is training to be an astronaut. While in the simulator, she experiences a sudden episode of synasthesia — a neurological condition where the senses get their wires crossed, and one can hear vision or taste sounds — and crashes. She wants to find and fix what is wrong with her, but doesn’t want NASA to know, so she offers House $50,000 to admit her and solve her case “off the books.”

House, meanwhile, has 40 applicants for his three underling positions. He presents Greta’s case to them but tells them that no records can be kept of her stay. Under questioning from the group, Greta reports that the symptoms are new and she’s never had similar episodes before. She has no psychiatric history and is on no medications of any kind. She does admit to doing a lot of flying as one student suspects that the prolonged immobility from flying has led her to develop deep vein thromboses (clots) of the legs, which are breaking apart and traveling through her circulatory system and a PFO (patent foramen ovale, an abnormal hole in the heart) and causing strokes, which caused her synasthesia. House orders an EEG, MRI, angiogram, and lumbar puncture, as well as a whole battery of lab tests. He also sends a trio of applicants to search her house.

The radiology studies are all normal, and the only significant blood abnormality is an elevated red blood cell count. The inspection of Greta’s apartment revealed a broken fireplace flu flue. The suspicion now is that she has developed carbon monoxide poisoning and she is placed in a hyperbaric chamber (a high pressure chamber that will drive the carbon monoxide out of her cells and replace it with oxygen). As she is getting set-up for the chamber, Greta develops tachycardia (an abnormally fast heart rate), tachypnea (an abnormally fast respiratory rate), low blood pressure, and passes out. The applicants start a code, providing CPR and code medications (but did they check a pulse before beginning CPR?). When the monitors show her to be in ventricular fibrillation, one of the applicants defibrillates her. It restores her to a normal heart rhythm, but also starts a fire in the oxygen-rich environment of the hyperbaric chamber. The fire is put out, and Greta is started on nitroglycerin and “blood thinners” (heparin, probably) for a suspected heart attack.

With symptoms now consisting of synasthesia, increased red blood cell count, and a heart attack, House throws the case to the applicants again. They suggest Takayasu’s Arteritis(inflammation of the aorta and other large arteries) and Whipple’s Disease (a rare bowel disease — which doesn’t seem to fit at all). An older applicant makes a good case for cardiomyopathy (a heart condition that leads to weakening of the heart muscle), and a transeosphageal echocardiogram is ordered (an echocardiogram that looks at the heart through the esophagus — it provides better images of certain parts of the heart, particularly the valves. Frankly, a regular echocardiogram should have been sufficient, but then we would have missed the reveal and character moment at the end). The echo reveals a structurally normal heart, but brief episodes of an irregular rhythm: atrial flutter. A thyroid problem is now the suspect, and a TRH stimulation test (an old and rarely used thyroid test) is ordered. As the test is administered, Greta’s heart rate and BP rise and she complains of feeling warm. She suffers another synasthesia episode as well as a psychotic break (or panic attack, depending on whom you listen to). She runs into a conference room and locks the door. She is persuaded to come out (threatened, really), and sedated — but not before Cuddy realizes something is going on.

The thyroid results were normal, so one of the applicants suggests a liver problem — more specifically: liver cancer with an associated paraneoplastic syndrome. The difficulty is that the Cuddy won’t let them run any more tests without the patient’s name on them, and the patient won’t allow her name to be used. House has to figure out how to diagnose Greta without running standard tests. An applicant suggests loading Greta with intravenous Vitamin D and placing her on a tanning bed (because Vitamin D requires sunlight to function effectively and is metabolized in the liver — but it would take a huge dose of Vitamin D to accomplish this ) while another suggests giving her tequila to see how much alcohol her liver can tolerate. Unsurprisingly, House goes with the tequila option. While House’s team is administering the test, Greta develops severe shortness of breath. She won’t let the team intubate her or give her oxygen because it will show up in the records. Listening to her lungs, House detects a mass and suspects she has lung cancer. Greta refuses a biopsy because it will leave a scar. One of the applicants, a plastic surgeon, suggests giving Greta a cosmetic procedure to explain away the scars, and performing a lung biopsy during the procedure. Reluctantly, Great agrees to a breast augmentation. The surgical lung examination reveals multiple cysts within her lungs. The diagnosis now includes Alveolar Hydadtid Disease (a parasitic disease caused by tiny tapeworms) and pulmonary Langerhans (a disease caused by a proliferation of a line of abnormal cells, in this case in the lungs), but none of them quite fit the case. Chase appears in the gallery and suggests Von Hipple-Lindau disease (a rare genetic disease that causes tumors and cysts to grow throughout the body) with a pheochromacytoma (a tumor that releases high levels of adrenalin and similar compounds, it can be associated with certain types of Von Hippel-Lindau). The Von Hippel-Lindau explains the masses and increased red blood cells, while the pheochromocytoma explains the cardiac and neurological symptoms. The cysts and tumors are removed, but Greta is cautioned that Von Hippel-Lindau is a genetic disease and they could recur at any time. House tells Greta that he has reported her situation to NASA, but it turns out that he is lying and he only told her that to stop the applicants from reporting it to NASA themselves. In the end he picks his applicants, confronts Cameron in the ER (where she now works), and accuses one of the applicants (correctly) of not being a doctor, but hires him anyway as an assistant.

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The medicine was mostly sound, though the team was jumping from one rare, poorly-supported diagnosis to another (but I can see that happening with a bunch of young doctors trying to outdo each other). Have you noticed how I’m not complaining about everyone running their own tests this year, but instead I’m going to stat complaining everytime people are in a surgical procedure without eye protection — it’s an OSHA rule! So far, House is 0 for 2, and Private Practice and Grey’s Anatomy are 0 for 1.

This episode marks a return engagement for the pheochromocytoma. Let’s give it a hand!

I give the medical mystery a B+, it was interesting and the constraints placed on the diagnostic options made it a little more exciting. The final solution I give a C because it came out of nowhere. The medicine was decent, though there wasn’t as much as usual; it earns a B. The soap opera was the best part, particularly the interaction among the applicants — I liked the old guy and Kumar, but Amber was too underhanded for my taste — an A for the soap opera.

The previous House review
A list of all prior House reviews
Tomorrow night I’ll be taking a look at the new ABC show Private Practice (Last week’s review can be found here)

Tags: television medicine house synasthesia thyroid von hippel lindau

Episode Title: In Which Sam Receives an Unexpected Visitor

Two significant cases this week: one was medically wrong and ethically murky, and the second was medically correct (if incredibly fast) but ethically wrong. I’m not going to say much about the stripper other than the rash appeared to be a resolving case of shingles (herpes zoster) from what little was shown. As for Violet, well the bicyclist in me was pained by her destruction of such a nice bicycle.

Dr. Cooper Freedman (with assistance from Dr. Addison Montgomery and Dr. Naomi Bennet)
Cooper has a patient, 9-month Emily O’Brien who is has been sick since birth and not growing well. She also has some poorly defined neurological symptoms. He runs some tests on her, including genetic testing, and determines that she is suffering from a severe form of the rare neurological disorder Pelizeaus Merzbacher. He runs tests on her parents and discovers that they are not carriers for the mutation responsible for Pelizeaus Merzbacher, and this makes him realize that Emily cannot be their child.
Looking through the hospital records, the team is eventually discovers that while Emily was in the nursery after birth, her real father switched his sick child with another couple’s healthy baby. Much pathos ensues when this is announced.

• Pelizeaus Merzbacher is an often fatal x-linked gene. This means that it is a disease that shows up in males, not females. Females are carriers for the condition, and can very rarely show mild symptoms, but full Pelizeaus Merzbacher cases (as Emily is said to be) are always males. This is a major mistake — there is no way that Emily can have Pelizeaus Merzbacher in that they’re describing.
• Any real infertility expert would cringe at Naomi’s line: “I didn’t promise you perfection, I promised you a baby.” The first part is true enough with any pregnancy, but no fertility doctor would ever “promise” any couple a baby. Even with all of modern science, the odds of an infertile couple conceiving is roughly 50%, and drops with each subsequent attempt. Promising success is inviting angry bitter couples and lawsuits.

Dr. Sam Bennet
Sam is making a house call on Dave Walker, a patient who is a known alcoholic. Dave is recently divorced and living with his teenage son and elderly mother. Arriving at the house, Sam finds him very sick with nausea and vomiting. An ambulance is called and Dave transported to the hospital. He improves after a short amount of time and is sent home, much to Sam’s dismay, with a diagnosis of viral gastroenteritis (the “stomach flu”).
Later in the same day his teenage son shows up at the clinic with identical symptoms. A check of his blood reveals coprine (scroll down to the bottom of the page), a toxin found is certain mushrooms. Coprine, we are told, works like “Antabuse” and causes a patient who drinks alcohol after ingesting it to become violently ill. Sam is able to determine that the patient’s mother is purposefully spiking his food with coprine-containing mushrooms to get him to stop drinking. Rather than tell Dave the truth about the poisoning, Sam tells him that he is allergic to alcohol.

• It’s amazing this all happens in one day: patient becomes ill and all his lab tests including cultures — which take several days to grow — are negative. The son becomes ill and his fancy and expensive blood tests are run and manage to come back the same day.
• Antabuse (generic name disulfiram) is a drug that interferes with the breakdown of alcohol in the human body. The alcohol is only partially metabolized and becomes acetaldehyde, a noxious chemical. This accumulates in the body and causes nausea, vomiting, and severe abdominal pain. Antabuse is prescribed in certain situations to help patients with alcohol problems stop drinking. It is not widely used because, in my experience, patients still drink when taking it, and now instead of an alcoholic patient, you have a violently ill still alcoholic patient.
  • Flagyl (generic name metronidazole), an antibiotic, has a similar effect on alcohol metabolism and we advise patients not to drink when on the medication, or even for several days after.
  • Pete is right that Coprine has the same effect as Antabuse.
• Never lie to patient. Sure, it’s tempting and seems like an easy way out sometimes, but it’s never a good idea. Sooner or later, they’ll find out and there goes all their trustin you. For another thing, how would you document it? Does Sam write in the medical record what really happened, the lie he told, or both? It’s a medicolegal nightmare. If the patient drops dead of coprine toxicity and the police discover Sam knew all along he was being poisoned, yet didn’t warn him or tell the police, Sam’s days of practicing medicine are long over.

Tags: television medicine private practice pelizeaues merzbacher coprine antabuse

Fantastic Four #549 “Reconstruction Chapter 6: So I guess You’re Saying the Honeymoon’s Over”
Dwayne McDuffie
Paul Pelletier

In a memorable and clever scene from Fantastic Four #549, Sue Richards puts the fear of God into the Wizard by threatening his life. More specifically, she threatens to use her powers to block his coronary arteries causing a massive heart attack. (Now is Sue making a real threat, or just bluffing? I leave that up to you).

Click here or the image on the right for the full scene.

♥  This is a good example of what I like to call “medicine on the attack”: characters who have enough knowledge of anatomy and physiology to cause significant damage when using their powers in a certain way. Iron Man and Battalion are two others who have made use of similar tactics. The heart always seems to be the target, but that makes sense because everyone knows where to find it, how important it is, and roughly how it works. The same can’t be said for most of the other organs (“Be careful Mole Man, or I shall crush your spleen!” just doesn’t carry the same weight) . I’ve also noticed it’s the “heroes” who are the ones making this type of attack.

♥  Despite what the Wizard says, it’s technically not a thrombosis because that refers specifically to a blood clot. You can’t fault him much for the wrong answer because no one has coined a medical term to describe an invisible forcefield blocking an artery.

♥  Sue’s plan is a little overkill. Blocking the three main coronary arteries (left anterior descending, circumflex coronary artery, right coronary artery) is more than enough to cause a fatal heart attack. Knocking out the left anterior descending alone should do the trick — it’s called the widow maker for a reason.

♥ The art looks a little misleading at first. In real life, the heart and lungs aren’t just sitting there free in the chest — they are both covered by tough protective membranes (the pericardium for the heart, and the pleura for the lungs). There’s a simple explanation though: Sue must have turned them invisible, just as she turned the Wizard’s skin and ribcage invisible. Overall, Pelletier’s command of thoracic anatomy is quite impressive.

♥ Personally, I think an even better tactic against the Wizard would be to threaten him with a stroke. Sure, threatening him with a heart attack puts his life at risk, but threaten him with a stroke and it’s his brain — his raison d’etre — that’s on the line. Just replace Sue’s comment about the coronary arteries with this line: “A man as smart as you surely knows what happens if I used a force field to close your carotid arteries.” He’d probably die of fright right there on the spot.

Tags: comics medicine fantastic four sue richards wizard heart attack

In this third-to-last issue of the 1989 series of Nick Fury, Agent of S.H.I.E.L.D., former S.H.I.E.L.D. ESPer Nina goes mano a mano (or whatever the telepathic equivalent is) with Psi-Borg, a Latverian Hydra double agent (trust me, it sounds much more exciting than it actually is).

Nina starts off with the standard psychic nosebleed, but as the battle becomes more intense, develops psychic ear-, eye-, and mouth-bleeding as well. She’s clearly seen better days.

And apparently her opponent Psi-Borg is a pirate. Or constipated.

Don’t feel too sorry for Nina, though. She gets the upper hand in the end:

PWOOSSHT! Remember that — it’s the sound of a head exploding. I hope you’re taking notes, because it will be on the test at the end of the semester.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed s.h.i.e.l.d. pwoossht

Endangered Species, Part 9
Christos Gage, writer
Scot Eaton, penciler

For the sake of argument — and comic book science — I’m willing to accept the face that there is a single “mutant gene” — the x-factor — that is present in all mutants. It has vastly different effects in different people, but it is a single gene.

However, in this exchange with the Dark Beast, Henry McCoy suggests that there is not just a mutant gene, but a mutant chromosome. This is a completely different kettle of fish. A chromosome consists not of a single gene, but hundreds — if not thousands — of genes, along with regulatory DNA, junk DNA, and various proteins.

A human has 46 chromosomes (23 pairs of chromosomes, 1 chromosome from each pair is inherited from each parent). If McCoy’s statement is correct, then mutants have 47 chromosomes — an odd number. That really screws up reproduction, inheritance, and meiosis, which rely on equal pairs of chromosomes to work right. It also makes be wonder why it took Marvel Universe scientists decades to find a blood test to detect mutants — an extra chromosome is hard to miss.

All this speculation is probably moot because most likely McCoy (or Gage) just misspoke and meant to say “gene” instead of chromosome. (…or else the mutant genome is more screwed up than I ever possibly imagined.)

I was also planning to rebut Hank’s bad HIV analogy (mainly that HIV is undetectable because there only a few copies hidden among the millions of cells of the human body, as opposed to the fact that each one of these millions of cells* has a copy of every gene), but the Dark Beast calls him on it in the next panel. When the Dark Beast smacks down your analogy, you know it’s a bad one.

Finally, let me just point out the irony of Henry McCoy, whose teammates include a man who shoots optic force beams from his eyes — Newton be damned — and another who has wings a fraction of the wingspan required to fly, dismiss something as “not scientifically possible.”

*Not counting red blood cells, which lose their nucleus (and thus chromosomes) early in their lifespan.

Tags: comics medicine x-men henry mccoy chromosome gene endangered species

A history of smallpox and smallpox vaccination from the pages of Ben Casey #2 (click on the image for the full page). It’s not exactly a current history of the disease as you’ll notice when you read the last paragraph — but it was current back in 1963, when this issue of Ben Casey was published. Technically, I guess smallpox could still be considered a “lurking menace” (but for different reasons now: biological weapon versus natural disease) — for the record, there hasn’t been a naturally occurring case of the disease since 1977 (and because I know somebody’s going to ask, there has been at least once case from a lab accident in the late ’70s. There have been some more recent vaccination-related infections, but the virus used for vaccination is vaccinia, a different virus than smallpox (variola)).

Tags: comics medicine psa smallpox ben casey

Another episode of House that focuses more on the applicants (or hirelings, if you prefer) and soap opera rather than the medicine. That’s not necessarily a bad thing, and it was an enjoyable episode soap opera wise. I just wish it had better medicine. Spoilers below!

The main patient tonight is Stark, a 37 y/o man with Spinal Muscular Atrophy, an incurable and progressive neurological disease that weakens muscles. He is wheelchair bound and assisted by his dog Hoover. While crossing the street, Stark faints without warning and is nearly hit by a car. He is admitted to the hospital to find out why he had the fainting spell.

House divides the ten remaining applicants into two teams of five each: boys versus girls. The team that diagnoses Stark correctly wins and gets to remain. The losing team is fired. Everybody’s favorite alpha-female Amber wants to join the men’s team but they rebuff her.

Both teams initially consider that Stark may have picked up a bacterial infection from his dog Hoover, but discard the idea. The women’s team now decides that he must have become infected with Strongyloides (threadworm) on his recent trip to Thailand. They treat him with Ivermectin, an antihelminthic drug (i.e. an anti-worm drug). The men have no working diagnosis and want to run a full battery of tests on Stark’s hair, blood, and stool. During this conversation, it is revealed that Stark is also incredibly constipated. Amber manages to finagle her way onto the men’s team by convincing them to try xenodiagnosis — basically, have a bug bite the patient, and test the bug for any parasites that the patient may have (of course, this would only test for blood-borne parasites, not ones in the intestines or other organs). In the middle of the test, Stark starts choking and coughing.

The next morning, House reveals that the patient has suffered an aspiration, but is improving on oxygen and chest PT (though the patient is shown receiving a nebulizer. Aspiration pneumonia, a nasty type of pneumonia, would be a concern in this patient). House seems intrigued by the women’s diagnosis of Strongyloides and dismayed that the men have only managed to run test after test. He places the men’s team in the “penalty box” — making them sit in his office and not talk about the case while the women go about proving theirs. Their plan is to perform a tilt table test on Stark and try to induce a fainting spell. If the test is negative and there is no fainting, then their diagnosis and treatment must be right (but not necessarily, the tilt table test only reproduces certain types of syncope — and not the type the patient has — and/or he might be getting better for other reasons beside their treatment).

Amber and the guys have not given up. They want to know whether Stark’s choking is dysphagia (difficulty swallowing) or achalasia (an esophageal motility disorder). The old guy suggests paraganglioma — a tumor in the neck that presses against the vagal nerve, thus causing fainting, whenever the patient eats. The tilt table test is negative, seeming to confirm the women’s diagnosis and treatment, but Amber runs a CT on Stark anyway. No tumor is revealed, but she believes the results are consistent with scleroderma, a type of connective tissue disease that commonly affects the skin and esophagus. House disagrees and fires the men and Amber. She’s not done though, she talks Chase into running labs on the patient for her. She wants to run an anti-centromere antibody test, a blood test that is sensitive for scleroderma. When she draws the patient’s blood, it turns out to be green.

With this finding, House “rehires” the men’s team and Amber because the diagnosis he thought was right clearly is not. The plastic surgeon deduces that the blood is green because the contrast for the CT the patient had the day before has not been filtered out by the kidneys meaning that Stark has kidney failure. (Who runs a contrast CT on a hospitalized patient without checking kidney function first? That’s very sloppy medicine by Amber, even if she did run the test herself).

The differential is now a gram negative bacterial infection from his indwelling catheter versus scleroderma. House orders Stark to be started on Ampicillin and Gentamicin, two potent antibiotics, for the possible infection; he also orders skin and lymph node biopsies to look for scleroderma. Shortly, the team reveal that the antibiotics are having no effect (though it seems mighty quick to make that judgment) and the biopsies are negative. Or are they? House notices some black specks in the cervical lymph node biopsy and suspects that Stark has melanoma of the eye that has spread throughout the body He wants to remove the eye and manages to talk Cuddy into agreeing with the surgery. Before surgery, the applicants are performing a thoracentesis (draining the fluid from around Stark’s lungs) to make his breathing easier when they notice the fluid is clear. This is not consistent with fluid from a cancer, which tends to be cloudy and bloody. Stepping in after House’s injury (discussed below), Wilson and the team decide that Stark has Eosinophilic Pneumonia, and he is started on corticosteroids and cyclophosphamide (a potent immune suppressant and chemotherapy drug, that has been used for certain types Eosinophilc Pneumonia). The medication doesn’t help and Stark dies quickly and quietly, his faithful dog by his side. When the dog is revealed to be dead a few minutes later, House realizes that Hoover took the patient’s Invermectin (which is fatal to that breed of dog) instead of the patient. Thus, the women were right and the patient had Strongyloides all along, and died of an overwhelming threadworm infection.

While the team is treating Stark, House sees a patient in clinic who pulls out a knife and sticks it in the wall socket right in front of him. House manages to revive him and the patient admits that he was in a car accident a few days previous and experienced a near death experience. He reports that it was the happiest that he’s ever been and wants to replicate the experience. Later, when Wilson accuses House of not knowing for sure whether there is an afterlife or not, House decides to find out for himself, and sticks the patient’s knife in a wall socket (but not before paging Amber). She performs CPR and manages to revive him, though he suffered a burned hand and an extended loss of consciousness. Because of this, Wilson had to take over Stark’s case in the end.

Meanwhile, at a hospital across town, Foreman is running his own diagnostic team, only he is trying to make it friendlier and more supportive than House’s. They have a patient with fever, boggy lungs, and blurry vision who the antibiotics aren’t helping. The team diagnoses Apergillosis and starts the patient on Amphotericin B. It doesn’t help, and the patient now develops yellow gums, a sign of jaundice. Foreman believes that the patient has anaplastic large cell lymphoma, a rare and aggressive cancer. He wants to start treatment right away. His boss disagrees and feels that a severe infection is most likely. He has Foreman start a potent antibiotic. Foreman’s gut feeling gets the best of him and he stops the antibiotic and starts the cancer therapy. He is correct and saves the patient life, but his boss fires him for not following the guidelines and putting his gut feelings ahead of medicine.

Medically, the episode was rather limited — which is to be expected in a story with six patients and more than a dozen doctors. The ultimate solution was interesting and not expected. I’m not sure exactly how the Strongyloides led to fainting, unless it was a severe case of disseminated Strongyloides, and even then it’s a stretch. The women never confirmed, or even tested for, the diagnosis of Strongyloides. Stool samples are the most common test, but it can take up to seven, but there is a good blood test for the infection. Most experts recommend at least two doses of Ivermectin, if not more. The disease progressed remarkably rapidly, but then Stark was in a debilitated condition, and given immunosuppressants, which are a bad idea with disseminated Strongyloides. It’s not generally the physician’s responsibility to make sure the patient takes the medication (I’m not sure whose it is — at some point, you just have to assume the patient wants to get better and trust that he will take the medication). I’m also unclear why the dog ended up with medication. Did he eat it of his own accord (his name “Hoover” suggests this may be a possibility), or did Stark feed it to the dog? If it’s the former, why wouldn’t Stark tell someone that he didn’t get his medication?

Just because a tilt table test was negative does not prove the diagnosis of Strongyloides. Tilt tables are best for certain kinds of fainting — for instance, orthostatic hypotension that occurs when people stand up suddenly. When was the last time Stark stood up? It’s a poor choice of tests to begin with, and did they have a positive test before treatment to compare it to? It’s basically a post hoc ergo propter hoc error.

Finally, where did House get the idea that the suspected cancer cells must come from the eye because the eye is the only thing that drains to that lymph node? Lymph node drainage is a lot more complex than that. An eye may indeed drain to one lymph node, but it is not the only part of the body that drains there.

As for the clinic patient — I am not an electrician — but wouldn’t you need to complete the circuit, that is have metal in both parts of the socket, for the electricity to flow (assuming the hospital is grounded correctly)?

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I give the medical mystery a C, as it was vague and not particularly unusual (fainting?). The final solution I give a B- because it was unexpected but should have been diagnosed and treated better. The medicine was uninspiring, and either team came close to convincing of their cases (and nor did House); it earns a C-. Once again, the soap opera was the best part, though — with the exception of Amber and Dr. 13 — the female characters were bland. Seeing Cameron and Chase was good (Cameron was easily manipulated, but Chase caught on — but still went for it), though I would have liked to see more depth in the Foreman scenes. Still, I give the soap opera an A.

The previous House review
A list of all prior House reviews
Tomorrow night I’ll be taking a look at the new ABC show Private Practice (Last week’s review can be found here)

Tags: television medicine house syncope spinal muscular atrophy strongyloides ivermectin scleroderma melanoma

Episode Title: In Which Addison Finds the Magic

A show primarily about marriages this week. Pete and his dead wife. Violet and her ex-husband. Naomi and Sam doing more of their infighting. And Addison whining. Plus more bad ethics. I expect this from Dr. House, it’s his shtick, but not from these doctors who are supposedly better and brighter.

Dr. Cooper Freedman
Cooper is brought to see a young girl who is blue. Not depressed, as he thought initially, but the patient actually has blue skin. He asks about dyes, inks, or any topical compounds that could have dyed her skin, but there have been no exposures. There was no other chemical exposure, by history. He ultimately decides that she has methemoglobinemia (an abundance of chemically-damaged hemoglobin in the blood) and treats her, correctly, with intravenous methylene blue. He in unsure what exposure lead to her developing the condition, but she responds to the medication. Over the next day or two, her skin turns blue again, as does the skin of her three younger sisters. One of the girls has a seizure as well. Cooper and the mother search the house, but can find no source of toxicity. He eventually talks the girls into letting him spend the day playing with them and they lead him to their “castle” – a neighbor’s old shed filled with leaking bags of the fertilizer ammonium nitrate. Nitrates are a known cause of methemoglobinemia and the girls are inhaling enough of the fumes to make themselves dizzy and their skin turn blue.
Methemoglobinemia is rare. There is an inherited form of the disease, but the girls have an acquired methemoglobinemia. It is treated with oxygen and 5 minutes of intravenous Methylene Blue followed by a saline flush (a big bag of blue IV fluid shouldn’t just be left hanging like it was in the episode).
Other possible causes of methemoglobinemia include certain older antibiotics, local anesthetics, nitrates, and metoclopramide (Reglan). There are a few unusual household chemicals that may cause it. Well water with a high nitrate content has been known to cause methemoglobinemia.
Inhalation of ammonium nitrate generally causes a nasty headache, cough, and sore throat — symptoms that were missing but would have helped narrow down the type and route of exposure.
I find it hard to believe that a parent who chose to stay at home to raise her kids is not going to notice her four kids regularly disappearing from the yard like that?

Dr. Addison Montgomery and Dr. Pete Finch
Addison has a newlywed couple as her patients who complain that they cannot have sex. Any attempt causes severe pain to the wife. Addison attempts an exam, but even that is too painful for the patient to endure. She diagnosis her with vaginismus. She tries muscle relaxants first, but they do not work. Next she tries trigger point injections combines with guided imagery. That works miraculously.
Vaginismus is a real condition, and difficult to treat. It is almost always psychological in nature.
The best treatment for vaginismus is a combination on counseling, special exercises, time, and understanding. It rarely resolves overnight.
I’ve never heard of muscle relaxants being used as a treatment. I can imagine that benzodiazepines like Valium might work, but more for their psychological effects than the physical ones.
If her problem is indeed caused by overly-sensitive nerves, then trigger point injection might work. Her issues seemed much more psychological to me, though, so I suspect Pete’s therapy did the most good.
For a “world renowned” surgeon, Addison has some lousy bedside manner.

Dr. Violet Turner and Dr. Sam Bennett
Violet has a patient named Doug who is unhappy in his marriage and wants a divorce, but is scared to tell his wife. After three years of therapy, she has finally convinced him to stand up to his wife and tell her what he wants. When he does, his wife’s nose starts to bleed uncontrollably and he brings her to the clinic for evaluation and treatment. Sam is able to control the nosebleed, but the patient’s labs show that she has a moderate anemia (low blood count).
A day or so later, the wife confronts Violet and she once again begins bleeding. Not just a nosebleed this time, but hemoptysis (coughing blood). She is admitted to the hospital and diagnosed with Wegener’s Granulomatosis, a chronic disease caused by inflammation of the blood vessels. After a confrontation with the hospital chief of staff, Sam discovers that the patient has known she has Wegener’s for at least 6 months and never bothered to tell the husband. He and Violet confront both the husband and his wife with the truth, but in the end Doug chooses to stay in his unhappy marriage.
There are good treatments for Wegener’s now, but it can still be a fatal disease. Relapses occur in about 50% of patients, and about 80% suffer some variety of long-term complication (deafness or kidney disease, most commonly). Survival rates vary, depending on the study, but around 75-80% can expect to live at least another 5-10 years with treatment.
No chief of staff is going to overrule an attending physician like that. It’s bad form and it’s not her job. Plus, it will drive doctors from the hospital. Hospitals like doctors, they make them money.
The confrontation in the end may have been within the letter of privacy laws, but clearly against the intent. You don’t threaten patients into sharing information with each other. The wife should have refused to tell them anything and reminded Violet that she had been fired as her husband’s therapist, so her husband would not leave the room with her. (OK, ideally, she should have told her husband the truth in the first place, but how likely was that to happen?).

Tags: television medicine private practice methemoglobinemia nitrates vaginismus wegener’s

New Warriors #5 “Defiant, part 5”
Kevin Grevioux, writer
Paco Medina, penciler

Just to prove I’m not always negative, I’m going to take a moment to highlight a comic that has a well written medical scene.

After blunt force head trauma, a concussion is the most common type of head injury. Concussions are diffuse injuries and affect the entire brain. (for a longer discussion, check out my review of Stormwatch PHD #11).

More serious — and thankfully less common — injuries following head trauma are the hematomas and hemorrhages — bleeding on (or around) the brain. Intracerebral hemorrhages, or bleeding within the tissue of the brain, can occur after blunt trauma, but are not as common as bleeding just outside the brain. Subdural hematomas are the most common. These occur when there is bleeding and a collection of blood between the dura (the tough membrane that protects the brain) and the arachnoid — the middle layer of the meninges (the membranes that surround and protect the brain). The hematoma causes increased pressure within the skull which can be life threatening, as well as direct damage to the areas of the brain underlying the hematoma. An epidural hematoma is similar, except the bleeding occurs between the dura and the skull itself.

Hematomas that are small can be monitored closely and should resolve on their own. Larger hematomas, especially those causing life threatening symptoms, require surgical intervention. The blood needs to be drained and — if possible — the source of the bleed found and stopped. This usually requires a burr hole or a craniotomy.

Of course, I do have a couple of small nitpicks, all regarding the art. Overall — as always — Medina does a good job with both the action scenes and the quieter moments. However:
If our patient just had cranial surgery, she should have her head bandaged, not in a surgical cap.
The art suggests that her burns were most likely to her back, in which case having her lie on her back like that just seems cruel (of course, we don’t know how extensive the burns are, they could be small and inconsequential).
The heart tracing bears little resemblance to an actual heart tracing, even in a case of cardiac arrest (the one on the cover is fine, though).

*For spolierific reasons, I’m not going to name the character, though she is shown injured on the cover.

Tags: comics medicine new warriors concussion subdural hematoma epidural hematoma kevin grevioux paco medina

I had always thought that this idea originated with Dr. Strangelove, but apparently Superman was the first (scene from Action Comics #22, March 1940)

Technically, Superman’s riding a torpedo, not a bomb, but the effect is the same.
Speaking of torpedoes, according to the IMDB, the scene in Dr. Strangelove was based on an old episode of Tom Corbett, Space Cadet where Tom rode an “atomic torpedo”, so maybe it does all tie in to Superman.

A map of Kamandi’s post-apocalyptic world, courtesy of Jack Kirby and Kamandi Archives, Volume 1.

Click on the Image for the Full-Sized Map

I tried to superimpose an actual map of North America (or at least the United States) over the image, but Kirby is using such an uncommon map projection that it was impossible to achieve a map that was not grossly distorted. Near as I can tell, I’m living at the point where the Gorilla Communes, the Tiger Empire, and the unnamed area just south of the Monster Lake all converge. Gives new meaning to the term “Gateway City.”

Kirby’s story doesn’t follow the map all the precisely anyway. In the comic, he has the Las Vegas area populated by members of the Gorilla Commune when the map shows it should be firmly in the area of the Lion Tribes.

Tags: comics kamandi jack kirby apocalypse

No House tonight because Fox is broadcasting the American League Championship Series (Go National League!). Instead, I thought I’d make some predictions about what diagnoses will show up on House this season. I didn’t do so well last time I tried to predict, but failure has rarely stopped me before (you’ll notice a lot of similarities between my two lists, I added some new predictions and lost a few.)

• Herpes Encephalitis.
• Kawasaki Disease.
• Delusional Parasitosis.
• Post-pregnancy Eclampsia.
• Dengue Fever
• Toxic Shock Syndrome
• Strep Throat (but mostly its rare but dangerous sequelae).
• Hanta.
• Oleander poisoning.
• Zoonotic diseases such as Babesiois, Ehrlichiosis, Tularemia, and Orf (and here’s a page on “Emerging Zoonoses“)
• cryptococcus gattii infection
• Commotio Cordis

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“The Challenge”
Make a list of ten conditions or diseases you think will show up on House. Be as specific as possible: no categories (like “cancer” or “autoimmune disease”), and no overly broad descriptions (”liver failure”or “cardiac arrest”, for instance). The list you make will last the remainder of the season — no addition, subtractions, or swaps. Put your list in the comments section.

Each week, your list will be compared against the show. Scoring is as follows: 1 point for a brief mention or one-liner. 3 points if the team actually tests for the condition. 5 points if the team treats the condition (or supposed condition). 12 points if it’s actually the correct final answer (or one of the answers) of the episode.

Scores will be collated each week and a running total will be kept. After the final episode of the season, a winner will be crowned!

My list: Herpes infection, Parvovirus infection, Lupus, Tularemia, Addison’s disease, Klinefelter syndrome, Cushing’s disease, Toxic Shock Syndrome, Cryptococcus gattii infection, Clostridium difficile infection.

Tags: television medicine house challenge

Episode Title: In Which Addison Has a Very Causal Get-Together

The medical ethics were better this week (except for everyone looking in other people’s medical charts), but the medicine was equally questionable. This show would really benefit from some Grey’s Anatomy style continuing storylines; this patients-of-the-week format just doesn’t sustain the interest here.

Dr. Addison Montgomery and Dr. Sam Bennett
After seeing Sam on a local morning news show, a pregnant patient named Rebecca arrives in the clinic seeking medical care. She claims that she just escaped from the hospital because they were trying to kill her and her baby. She is five months pregnant, but surprisingly skinny. In short order, it turns out that she was involuntarily committed to the hospital because she was a psychiatric patient with Munchausen’s Syndrome, and now the hospital – and her mother whois her medical guardian — wants her back in the psychiatric ward.
Addison is not convinced that Rebecca has Muchausen’s, though some lab values which suggest she has not been eating give Addison pause. In the end, the team gets the hospital to run a capsule endoscopy (”GI camera”) which reveals that Rebecca has Crohn’s Disease — a type of Inflammatory Bowel — and not a psychiatric disorder.
Five months along and she is just now feeling the baby kick? That’s not a good sign.
I’m concerned by the amount of x-rays and CT scans performed on Rebecca. There was an entire wall full. Radiation is not good for developing babies. (And if the Crohn’s was that bad, something should have shown up on the CT).
Involuntary psychiatric admission laws vary greatly between states and I’m not familiar with the laws in California. I can see an involuntary admission being granted in this case though, for fear of Rebecca harming herself and harming her baby.
I’m not sure what labs would show Rebecca hadn’t been eating when she claimed she had been. Albumin and other proteins can be low in malnutrition, but that’s in the long term, not short term. Ketones in the urine can also suggest starvation — though it can mean other things as well including diabetic ketoacidosis and an Atkins dieter.
I don’t know why the team was thinking they could get a capsule endoscopy performed in under an hour. It takes the better part of a day to run a capsule endoscopy, let alone the prep beforehand. An actual colonoscopy would be faster and give more definite answers.
There are simple blood tests to detect active autoimmune diseases. They’re not always good at pinpointing which disease in particular, but would at least let the team know that something physical is going on.
Sam uses the word “occult” way too many times in this episode.

Dr. Cooper Freedman
Cooper was dealing with Michael, a ten year-old boy who was in love with a friend. When Cooper encourages Michael to ask his friend out, the boy returns to the office bruised and bloody. It was not a girl he asked out, but another boy. Now he runs away and Cooper — of course — finds him and manages to bring him back home.
No skateboarding or contact sports if you have Mononucleosis because the spleen can become enlarged during Mono and there is a chance of rupturing it with any blunt trauma.

Dr. Violet Turner and Dr. Naomi Bennett
Violet become obsessed (well, more obsessed) when she sees her ex-husband’s (or is it ex-boyfriend’s — it’s not clear) new wife visiting Naomi. It turns out she was there to be treated for a urinary tract infection, not pregnancy as Violet feared.
Violet’s one note characterization is quickly becoming tiresome.
What kind of doctor is Naomi exactly? Who goes to see a fertility specialist for a UTI?

Dr. Pete Finch
Pete is seeing Stan, the curmudgeonly fiancée of Sylvie, an old patient of his. Stan has been having fainting spells and Sylvie is secretly concerned that the fainting spells are a subconscious sign that Stan does not want to marry her. Pete runs some “basic tests” which are all negative, but after some more probing, he determines that the Arthur has a “trigger point” that causes a “painless migraine” (a type of Atypical Migraine) which causes him to pass out when he is in certain positions.
An EKG, echocardiogram, and carotid Doppler all are good tests for this situation. Some sort of head imaging is indicated, but I would never consider an MRI a “basic test.” Maybe that’s just because I practice in small town Illinois and not a big city in California.
As for a muscle trigger point causing a painless migraine, that’s a rather cavalier diagnosis. I have seen atypical migraines that cause symptoms that look just like a stroke, but never one that causes passing out, one that shuts one and off that quickly, or one caused by a “trigger point.” I’m not saying it can’t happen; it’s just quite a stretch.

Tags: television medicine private practice munchausen’s syndrome crohn;s disease syncope

With all the characters with shrinking powers in comic books, it was only a matter of time before they started shrinking small enough to enter someone’s brain. Most of the time, the miniaturized character enters the brain to cause damage, but sometimes it is done to heal. While most common in the comics, this concept can also be seen in movies (Fantastic Voyage) and television (The Simpsons in their spoof of Fantastic Voyage, Futurama, Astroboy).

Once the shrunken character enters the brain, there are four basic “Styles of Attack”:

1. Crude and Deadly
This style occurs when a miniaturized character blunders haphazardly through the brain itself, doing as much damage as possible along the way. This is best exemplified by Jean Loring’s murder of Sue Dibney during Identity Crisis.
A more recent example had Micromax take out a leader of the Jihad in a similar manner in Marvel Comics Presents #1 (see the image below — that’s Micromax climbing out the ear; I’m not sure what that line is in the background – heart monitor? brain waves? biothythms?). Symptoms he caused included headache and seizure as well as the ubiquitous nose and ear bleeding (and death).

2. Surgical Precision
This style is most often utilized in a curative manner rather than as a weapon. The best example is actually a movie, not a comic book. In Fantastic Voyage, five adventurers and their submarine are shrunken so that they can remove a clot in a Soviet defector’s brain. A good comic book example would be Micronauts #30, where Acroyear, Bug, and Marionette are miniaturized and enter Commander Rann’s brain to cure his coma. They battle and defeat Nightmare and are able to physically unlock hidden areas of the commander’s brain.
Conceivably, precise strikes by a tiny character could also be used to damage specific parts of an enemy’s brain…but I can’t recall any good examples of this.

3. Vague but Effective
This is the most common style. A menacing villain looms up behind the heroes, ready to strike. Suddenly, they collapse in a heap and the Atom/Shrinking Violet/other-tiny-character jumps out of their ear. It’s never explained exactly what they did inside the villain’s brain (Squeezed the blood supply? Caused a seizure? Kicked something important?) — but it sure knocks them out quickly.

4. Haney-style
In the destined-to-be-classic Brave and the Bold #115 (written by Bob Haney, art by Jim Aparo), Batman is electrocuted and rendered brain dead but the Atom is able to enter his brain through the ear and control Batman like a puppet. Sure, it makes no sense anatomically, but then, Haney written titles always followed their own unique science. The Atom also manages somehow to kick-start Batman’s brain again after capturing his murderer and saving the day.

Other Comic Book Diagnoses:
Frozen Solid
Brains! Brains!
Hypertrichosis
Xenografting
De-Aging

Tags: comics medicine brain identity crisis micromax fantastic voyage micronauts atom batman baob haney

Script by Paul Levitz, Pencils by Keith Giffen

As suggested by various commentators in the previous post, here is a perfect example of the “Surgical Precision” style of taking down an enemy from within: in this scene from Legion of Super-Heroes #294 (the concluding chapter of the Great Darkness Saga), Shrinking Violet (well, Yera really) causes a stroke in one of the Servants of Darkness by blocking blood flow in their brain.

Tags: comics medicine brain legion of super-heroes shrinking violet stroke

There are so many incredible pages of the Atom running through Batman’s brain in The Brave and the Bold #115 that it’s hard for me to pick just a few panels to highlight. But somehow, I did.

Courtesy of Bob Haney and Jim Aparo, here’s the Atom running around inside the brain of a brain-dead Batman, stimulating various parts of his brain, and using him like a puppet to track down and apprehend the crooks who killed him.

Tags: comics medicine brain batman atom bob haney jim aparo

It may be a few days early, but this seemed the perfect time for this PSA from Adventure Comics #297 (June, 1962) which celebrates United Nations Day, October 24th, the day in 1948 when the United Nations charter became official. According to the U.N., each member nation is supposed to celebrate United Nations Day as a public holiday. I don’t know about you, but I’ll be working a full day on Wednesday with nary a holiday in sight until Veteran’s Day. So much for United Nations Day as a public holiday — in the U.S.A. at least.

Click on the Image for the Full-Sized PSA

(I don’t know about anyone else, but I detect a little bit of Western World smugness in this celebration of children…or maybe I’m just being overly cynical.)

This PSA was written by Jack Schiff with art by Bernard Bailey. It was sent my way by the industrious H over at The Comic Treadmill.

Tags: comics psa united nations jack schiff bernard bailey

After Episode 4, Sarah is in the lead with 12 points, Case has 6, Chimmie has 5 and about 11 people have a score of 3. A whole bunch more (including me) have zero points.

Full standings can be found here (and a link will eventually be placed on the sidebar)

An enoyable and quick-mving episode of House, albeit one without much medicine in it. The mystery was intriguing, the solution logical, and the soap opera progressed well. Spoilers below!

Irene is a 24 year old Ukrainian immigrant who works as a funeral home cosmetologist. At work one night, she hallucinates that she is attacked and raped by two dead men. She starts screaming and her boss rushes in to find her in a full tonic-clonic seizure on the floor. She is admitted to the hospital and House and his team take over the case.

The initial differential diagnosis includes a temporal lobe tumor (but the CT was normal), toxic chemical exposure, or STD (which was dropped and never mentioned again). House sends part of his team to investigate the funeral home and Irene’s apartment; the rest he has run an MRI, EEG, LP (lumbar puncture, i.e. spinal tap), and a generic “blood panel.” The studies are all negative. The search of Irene’s apartment reveals little besides a plethora of organic foods. The funeral home search turns up no smoking guns, but Mormon Guy is suspicious of ethanol toxicity from the embalming fluid (which was already ruled out in the ER), and Old Guy points out that a recent cadaver at the funeral home died of something that sounds suspiciously like Mad Cow Disease (which they identify as Creutzfeldt-Jakob Disease). House sends the team to disinter the body of the suspicious cadaver and run tests on its brain — tests that end up being negative.

Irene is insistent on going home and the team is ready to release her when they realize that she has been carrying on a conversation with her dead mother. Old Guy points out that this is both a hallucination (talking to someone who isn’t there) and a delusion (believing her mother is alive when she died 20 years before). Plastic Surgeon suggests carbon monoxide poisoning while Old Guy believes that she may have an inherited disease of some sort. Irene’s mother died young, at age 25, and he suspects Irene may have the same disease, whatever it may have been. House tells the team to run tests for every hereditary disease, starting with Amyloidosis and continuing through to “Zamyloidosis.”

Around this time, Dr. 13 and Amber discover that Irene is seeing not just her mother, but other dead people as well, including a wheelchair bound man with a dead dog (Stark? From the previous episode?). When House talks to Irene, she tells him she sees his grandfather Walter. After hearing this, House leaves the room in a hurry, but he confesses to Wilson that it was all a ploy to make Irene think he believed her –– House actually has no grandfather Walter. He returns to the room and — through Irene — elicits some history from her mother to narrow down the cause of her premature death. Her mother was tired, unsteady on her feet, had a tremor, and walked bent over. From these symptoms House deduces that Irene’s mother died of Parkinson’s Disease. It matches Irene’s symptoms as well, so he starts her on L-dopa and Bromocriptine.

Irene now hallucinates that Dr. 13 and Kumar are stabbing her. When Dr. 13 tells her it was a dream, Irene points out that her arm is bleeding as if she had been stabbed. These new symptoms lead the team to consider retinal vasculitis and acute intermittent porphyria. Tests for both are run while she is started on corticosteroids, the treatment for vasculitis. While undergoing a retinal test, Irene starts complaining of abdominal pain and begins to vomit blood. The next thing we know she is in surgery with Chase (and since when was he a surgeon?) who finds an enlarged spleen and a necrotic liver. Old Guy still believes she has a vascular disease of some sort, so a visceral angiogram is ordered. As the test is proceeding, Irene begins to grope Mormon Guy and has convulsions, delirium, and hypersalivation. During this discussion, House continues to poke fun at Mormon Guy who finally has enough, and punches him. One of House’s comments rings a bell with Amber and she realizes that Irene is suffering from Ergot poisoning. Ergotism is caused by Claviceps purpurea, a mold which grows on rye grain (Irene’s organic food). Its symptoms include hallucinations, seizures, constriction of blood vessels, headaches, nausea, vomiting, and dry gangrene. It is thought by some to be the underlying cause of the infamous Salem Witch Trials. After treatment, Irene’s symptoms resolve and she bids a tearful farewell to her dead (again) mother.

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The medicine, although there wasn’t much of it, was decent this episode. Not much time was spent on preliminaries and the obscure diagnoses came quickly. The writers were stretching on quite a few of the ergot-related symptoms (like the almost-stigmata, where did those come from?) and ergotism usually has a distinctly different presentation than Irene, but when has anything on House presented normally? Irene’s normal MRI, EEG, LP, and blood tests rule out most of the other causes besides a toxin of some sort — just what it ended up to be.

Also, Mad Cow is new variant Creutzfeldt-Jakob Disease, not classic CJD.

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The medical mystery was interesting, though most of the symptoms were vague and added as afterthoughts (”By the way, she has focal weakness and urinary retention, we just didn’t feel like mentioning it earlier.”) — I give it a B+. The medicine was a little more focused than recent episodes, but still seemed more show than substance — it earns a B-. The solution was logical and actually fit most of the symptoms and earns an A-. The soap opera could have used more Wilson, but otherwise was strong, especially the last Cuddy and Foreman bit. It also earns a B+.

The previous House review
A list of all prior House reviews

Challenge scores are in the post immediately beneath this one (or click here)

Tags: television medicine house hallucination parkison’s disease vasculitis porphyria ergotism

Justice League of America #13 “Unlimited Chapter 2”
Dwayne McDuffie, writer
Joe Benitez, penciller

Poison Ivy: It’s the flora in your digestive tract. Mycobacterium paratuberculosis to be precise. They’ve octupled in population by now.
Poison Ivy: That’s not going to get rid of them, dear heart. They’re quite a bit deeper than your stomach.
Poison Ivy: If I hadn’t just called them off, you’d be well on your way to a bad case of colitis. But I didn’t want to be around for the explosive diarrhea.

Mycobacterium paratuberculosis* is an interesting choice of bacteria for Poison Ivy to use. As the name suggests, it is a member of Mycobacteriaceae, the Mycobacterium family. This is the family of bacteria that contains the germs responsible for both tuberculosis and leprosy. While most bacterial infections take place outside of the actual cells of the body, in the surrounding tissues and fluids, Mycobacteria are one of the few types of bacteria that manage to infect and live inside the cells of the human body. This makes them difficult to detect and hard to treat, usually requiring long courses of multiple antibiotics.

There is controversy regarding how infectious M. paratuberculosis is in humans, or whether it is infectious to us at all. It does not cause the acute gastroenteritis John demonstrates, with abdominal pain and vomiting (but maybe Poison Ivy just souped up virulence of the germ). he bacteria may cause the diarrhea she threatens him with later: there is a suspicion that M. paratuberculosis may somehow cause or be related to Crohn’s Disease — an inflammatory disease of the bowel — because it is known to cause a similar condition in cattle (Johne’s Disease) and it has been found in patients with Crohn’s. However, curing the infection appears to have no effect at all on the Crohn’’s, so there is debate about how much the germ is actually involved in the condition. That’s pretty much it in terms of what we know about M. paratuberculosis and human infections.

Also, since when have Poison Ivy’s powers been able to affect bacteria? As far as I know, they’re only effective against plants, and that’s a separate kingdom entirely. Of course, this is only an initial chapter of the story, so maybe Ivy’s expanded powers will be explained later (I blame Luthor. That’s almost always a safe bet).

*also known as “Mycobacterium avium subspecies paratuberculosis” or “Map.”

Title: In Which Addison Finds a Showerhead

Tonight’s episode tried a little too hard to be clever and suffered for it. Plus, once again, we get a storyline involving Violet and her ex. Enough already! On the other hand, the medicine was a little better.

Dr. Sam Bennett and Dr. Violet Turner
One of Sam’s patients surprised a burglar in her house and is injured and traumatized from the incident. She asks Sam for a pill that will make her forget what happened. As the show progresses, Sam brings Violet in to talk to her and we discover that she was sexually assaulted by the intruder. Sam and Violet, in a miraculous single session, manage to cure the patient’s post traumatic stress disorder (PTSD), and then cause — and cure — PTSD in her husband.
As Violet suggests, there has been discussion that Propranolol (usually used as a blood pressure pill) may ease the psychological effects of the trauma, but will not erase the memories. There was a small study published in 2002 supporting this use of Propranolol, but the numbers were very small and the results did not seem all that impressive to me.

Dr. Addison Montgomery
Maya, Sam and Naomi’s daughter, comes to visit Addison with a friend from school because Maya is scared she may have gonorrhea, a sexually transmitted disease. Maya is tested but shows no sign of the infection. Later, Maya calls Addison frantically because her friend has collapsed in a pool of blood. It turns out that it was not Maya who was sexually active, but her friend, and this friend has a life threatening ectopic pregnancy. Addison rushes the girl into surgery and is able to save her life.
Ectopic pregnancies are pregnancies that occur outside of the uterus. They are most commonly found in the fallopian tube, but can happen anywhere in the abdomen. They can extremely dangerous and life-threatening, particularly as the pregnancy advances.

Dr. Pete Finch
Pete is asked by a former patient of his, a college track coach, to take a look at his star runner. She claims she is fine, but Pete hears wheezing so he brings her into the hospital for a pulmonary/cardiac stress test. During the test, she has a severe bronchospasm (think: asthma attack), and the Pete and the hospital chief of staff tell her that she needs inhaled steroids and “continuous neb.” (nebs = nebulizer, a machine that vaporizes medication so it can be inhaled) She refuses because a big track meet is coming up and she will not be able to compete while on those medications. When neither she nor the coach returns Pete’s calls, he travels to the college track to find her and arrives just in time when she collapses at the end of a race. While in the hospital, it is discovered that she has some “alkaloid” in her system. Pete finds out that she had visited another doctor who had given her some kind of herb, which along with the bronchospasm, nearly killed her and may prevent her from ever competing again. When Pete finds out that the coach is to blame, he slugs him.
The most common cause of bronchospasm is asthma. Exposure to nasty fumes or allergens (including food allergies and bee stings) can also cause it. Severe cases of bronchitis or emphysema can also lead to bronchospasm. If I had a world class runner who suddenly developed bronchospasm, I would wonder why this occurred all of a sudden. Asthma should have shown up much earlier in her career. It’s most likely that she has been exposed to something recently that caused it, and discovering the cause would solve many of her problems.
If the patient is in such severe bronchospasm that she needs continuous nebs, then it would be prudent to actually give her a nebulizer instead of just sitting around about it. Albuterol nebs are usually given every two to six hours in cases of significant bronchospasm. Rarely, they can be given continuously, but only in very severe cases (and these patients have bronchospasm so bad the patient is not able to talk, let alone argue).
The alkaloid she was given would likely be ephedra or ma huang — which would show up on athletic screening drug tests. In fact, any herb that would have an actual beneficial effect on her breathing would show up on a competition drug test. That’s a lot harder to explain away than a prescription medication.

Tags: television medicine private practice post traumatic stress disorder gonorrhea ectopic pregnancy bronchspasm

Last year, I criticized Marvel for neglecting to include artist credits in the Marvel Legacy 1980s Handbook.

I’m pleased to report that this situation has now been remedied. I’ve been informed that the soon to be published collected edition of the Legacy Handbooks will include full artist credits. In addition, the credits will be posted on Marvel website.

I appreciate Marvel taking the time and effort to set things right.

Squasha has been promoting an excellent idea: instead of candy, hand out comics to Trick-or-Treaters.

I think this is a brilliant concept. I’ve always stood behind clever ideas for getting comic books into new reader’s hands, and this fits the bill perfectly. So this weekend, swing by your local comic shop and pick up a bunch of quarter books to hand out on Halloween.

And let’s face it, dentists make enough money already — we don’t need to give them any more business.

• Comics4Halloween website
• Comics4Halloween flyer

I mentioned Poison Candy before when it was available as a preview, but now I have my hands on the entire first volume. The story centers on 16 year-old Sam and his friends and family. Shortly into the book, we learn that Sam has contracted SKAR, a mysterious virus that strikes adolescents and is uniformly fatal within a few months. It’s not all bad: the virus also confers psychic powers, but the more the powers are used, the quicker the virus kills the host. A strange benefactor arrives at the door — he offers Sam the chance for a cure, but the cure comes at a high price. And that’s all of the plot I’m willing to give away.

The book is entertaining and solid, and the art — while a little sketchy at times — fits the mood well. My only concern with the book lies not with the creators, but the publishers. TokyoPop is notoriously slow in getting subsequent volumes of its OEMs to the shelves. Poison Candy sets up an fascinating scenario in its last few pages — how long will we have to wait for the next volume?

Anyway, here’s the main character Sam after ending a confrontation with some local gang members.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine manga poison candy

More Poison Candy. This is Suzi, who just wants to go home.

Personally, I’d listen to her.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine manga poison candy

From the June 1961 issues of assorted DC comics comes this PSA which reminds us — just like the title says — that parents have rights too.

Looking more closely, it’s not that the parents have given up any rights — it’s more that their kids are being brats. So is this a warning PSA for kids, or a cautionary one for parents? You decide (personally, I’m leaning toward the latter).

Click on the Image for the Full-Sized PSA

This PSA was scanned from Action Comics #277 and is written (as always) by Jack Schiff with art by Bernard Baily.

More PSAs

Tags: comics psa parents jack schiff bernard baily

High scores for this episode go to Bubba with 5; flambinca with 4; and Jbob, Chi, and proudfoot with 3. Several players scored 1, most scored nothing.

Overall, after Episode 5, Sarah retains the lead with 12 points, Case is in second with 6, but Jbob moves up to tie for second. Chimmie drops to fourth and is tied with Bubba.

Full standings can be found here (and a link will eventually be placed on the sidebar, promise)

A relative weak episode of House, medically. Foreman returned, and it was good, but the mind-reading/mimicking patient blew my suspension of disbelief.
All in all, while Mirror Mirror was one of the best Star Trek episodes, the same cannot be said of House (it’s not an awful episode , just mediocre). Anyway, spoilers below!!

A man walking down the street is mugged and starts coughing and wheezing during the attack. As he falls to his knees in respiratory distress, one of the muggers feels bad enough to call for an ambulance (but not bad enough to return his wallet). The patient, who identifies himself as Martin Harris, is admitted to House’s team for evaluation of his respiratory collapse.

The initial differential diagnosis includes asthma (not supported by the x-ray), food allergy (no skin findings), and pulmonary embolism (a blood clot in the lungs — but radiology studies were normal). Foreman suggests laryngospasm (a sudden tightening of the vocal cords) as a diagnosis. Though he is not happy about Foreman being present, he recognizes that his suggestion has merit and orders a methacholine challenge. The test is negative, though now the patient complains of numbness in his extremities and abdominal pain. The differential diagnosis now consists of dissecting aortic aneurysm, a spinal cord lesion, or multiple marantic emboli (clots from growths on the heart valves). None of them seem to fit the symptoms well, but the team is interrupted mid-discussion with the news that the patient has had a syncopal episode and collapsed.

As they are evaluating Martin, Foreman begins to suspect Munchausen’s Syndrome because the patient “borrowed” the name of one of the paramedics and his new symptoms match the exact symptoms of his neighbors. House, instead, suspects Giovanni’s Giovannini’s Mirror Syndrome, where a patient who has lost his memory mimics those he sees around him. House brings Martin into the operating room where Wilson is performing a procedure. Sure enough, Martin begins to mimic Wilson, confirming the Mirror Syndrome diagnosis.

A short time later, House and the team notice that Martin has a lace-like rash over his arms and legs (livedo reticularis), which House decides is due to cold agglutinins (antibodies that clot in the cold, blocking capillaries and blood flow) caused by infection. Blood cultures are ordered as well as an ultrasound. House sends Dr. 13 and Big Love to search for the patient’s car to find out who he really is. A solid liver lesion turns up on the ultrasound — the thought is either an abscess or a vascular hemangioma (a clump of dilated capillaries). Frat Guy performs a needle aspiration and gets a dark substance he believes is pus. He suggests that Martin has a tropical fungal infection and the patient is started on Amphotericin. The livedo reticularis returns and Martin is placed in a heated whirlpool. The Amphotericin does not help and what was felt to be pus ends up just being coagulated blood. The differential remains infection, but most likely viral or some rare bacteria. Because the patient has no memory, they can’t get a good history, but House suggests they run antibody tests on Martin’s blood and cerebrospinal fluid (CSF) because this will give them some idea what diseases he’s been exposed to in the past and a general idea of where he is from and where he’s been. His antibodies are high for histoplasmosis (common in the Ohio River Valley) and weak for coccidiomycosis (found in the San Joaquin Valley) and Chagas Disease (common in Mexico and Central and South America).

The livedo reticularis has returned despite aggressive hot water baths. House starts Martin on lipopolysaccharide (a toxin found on the cell wall of certain infectious bacteria) to induce a fever to raise his temperature and keep his blood flowing. While in the tub, Martin goes into cardiac arrest. Kumar defibrillates Martin before he is completely dry. This returns Martin to a normal heart rhythm, but also knocks Kumar out.

House orders a re-check of the blood cultures and Foreman recommends a heart biopsy. As Dr. 13 completes the heart biopsy, Kumar drops a hint to House that Martin regained some of his old memories while in the hot tub. Taking the items found in the patient’s car by Big Love and Dr. 13, House pretends to be Robert Elliot (the patient’s real name) in an attempt to jog the patient’s memory. With the help of vaporub, he succeeds and discovers that Robert/Martin is a traveling farm equipment salesman and has developed an Eperythrozoon infection from pig feces (a type of bacteria found in certain animals, including pigs and ruminants. It has been known to infection humans on occasion, though I can find no listing of serious infections).

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There was too much bad reasoning in this episode for the medicine to be very good. Everything magically clicked into place when it shouldn’t have. Sure, methacholine can be used to detect laryngospasm, but it is better for inducing asthma – also on the differential diagnosis list. Sure, infection can cause cold agglutination, but so can many, many other things including vasculitis, autoimmune diseases (Lupus!), cancer, and tuberculosis, just to name a few.

I don’t have much to say about Giovannini’s Mirror Syndrome, because I can’t find any information about it. Whether it exists or not (and I suspect it does in some manner), the way it was presented was too unbelievable. A patient would take on characteristics of those around him, but not be magically able to see deep into their psyche; they wouldn’t become omniscient. And if patients with Mirror Syndrome do mimic the strongest personality about them, why would he copy Wilson in the ER and not House, who is clearly the dominant personality. Why did he pick one name and stay with it? Wouldn’t he pick a new name every time he encountered someone dominant? Shouldn’t he be Gregory House?

The temperature of cold agglutination does not increase as the patient becomes sicker, certainly not to over 100 degrees. Anyway, giving someone a bacterial endotoxin to cause a fever is not a good idea because it causes other serious effects besides just fever.

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Funniest Line (intentional):

House (to Cuddy): I know when my Vicodin isn’t Vicodin. Do you know when your birth control pills aren’t birth control pills?

Funniest Line (unintentional):

House: He’s got Mirror Syndrome.
Foreman: Giovannini’s?
House: Do you know another Mirror Syndrome?

(um, how about Maternal Mirror Syndrome from last season?)

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The medical mystery was interesting, though the symptoms were stretching incredulity — I give it a B. The medical aspect forgot the whole idea of differential diagnosis, and chose certain causes without reason. It wasn’t wrong, per se, as incompletely thought out. The Giovanni’s Mirror Syndrome seemed a little too convenient, too. It earns a C. The solution was yet another strange zoonotic disease, but not one really considered as dangerous as the show suggested; I give it a B-. The soap opera with Foreman and House and Cuddy was good (as was Chase running a betting pool), but Martin reading everyone’s mind was too much of a stretch: B.

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Tags: television medicine house mirror syndrome livedo reticularis cold agglutinins eperythrozoon

Title: In Which Charlotte Goes Down the Rabbit Hole

The medicine in this week’s episode was straightforward and basically just used to set up the dramatic confrontations of the show. One of the better episodes so far, actually. And Violet only scored a 2 on the “whiney scale.”

Dr. Naomi Bennett and Dr. Addison Montgomery
Naomi and Addison are evaluating Angie and Ray, a husband and wife, for infertility. The wife’s work up was normal, as was her husband’s. Angie asks the doctors to tell Ray that he’s infertile because she does not want to have kids and has been secretly using contraception. Addison and Naomi (for once showing some ethics) tell her that they will not lie to her husband and that she needs to tell him the truth.

The next day Angie comes back and explains to Naomi and Addison that her grandmother and mother died of Huntington’s Disease, and she is afraid she might have it as well; this is why she does not want to have children. Huntington’s is a particularly nasty inherited neurological disease. Symptoms are progressive and include an abnormal gait, uncontrollable body movements, dementia, and emotional changes. It is especially heartbreaking because most people don’t realize they have it until they’ve already had kids, and half of those kids will have inherited the disease. Huntington’s is incurable. Angie tells the doctors that she wants to be tested for the Huntington’s gene.

The test is performed and comes back showing that Angie has the gene and will develop Huntington’s (though they share the news with her in a horrible way — “before we tell you the results, we want you to meet our psychiatrist, you know, just in case…”). Horrified by the results, she packs up and leaves her husband. Naomi and Addison convince her to return home and live what time she has left to the fullest. Angie tells Ray the truth and they both decide to go ahead and start a family (despite the 50% risk of passing the gene along — I think adoption would be a good option here).

Dr. Violet Turner
Violet only mentions Allan once and then only in passing. Good job.

Dr. Cooper Freedman and Dr. Sam Bennett
Cooper is treating Tess, a teenage girl, for a wrist fracture that she explains happened when she tripped over a curb while walking and reading a book at the same time. While casting her arm, he notices a suspicious looking bruise. Looking back through her records, he finds that Tess has been seen multiple times for falls, bruises, contusion, cuts, and so on. Not just recently, but also before they moved to the area. He suspects abuse by the mother, one of Sam’s patients.

Marilyn, Tess’s mother, has multiple sclerosis and is a well respected writer that Sam refuses to even think could abuse her child. She, of course, denies any abuse, and the daughter does too. Eventually Cooper gets Tess to admit that her mother does hit her. Belatedly, Sam realizes that she is abusing Tess and he missed the sings. He shows up in court to show support for Cooper when he testifies at the child abuse hearing.
Cooper was absolutely right in this situation. The laws of most states (including California) give doctors no option — any suspicions of child abuse must be reported. Not to do so risks losing your license at the very least. Sam, on the other hand, could be seen as hindering the investigation since he suggested (or at least implied) that Cooper not report his suspicions.

Dr. Peter Finch
Charlotte King, the bossy hospital chief of staff, comes to see Sam because she has been unable to sleep. He performs a full neurological exam (though he needs to work on his ophthalmoscope skills) and finds nothing physically wrong. He offers her some sleeping pills, but she declines for reasons she refuses to explain. He refers her to Pete.
Pete tries a variety of “alternative medicine” techniques to help her sleep, but none of them work (which is what I’d expect. Melatonin has been shown not to be beneficial for insomnia, and the very idea of magnets taped to the face changing the blood flow in the brain is laughable). He sends her to Violet who reports back that Charlotte has intimacy issues. Pete tries one last concoction, but mostly just listens to Charlotte and lets her talk, and she finally manages to fall asleep. The next morning, she dismissed it all as hogwash, but ends up leaving with a variety of “alternative medicines” to try (as opposed to dealing with her overly-Type-A personality, the real reason for her insomnia).

Tags: television medicine private practice huntington’s disease multiple sclerosis child abuse insomnia