Polite Dissent

A strongly mediocre episode of Fringe. At least the science and medicine wasn’t too bad this time around.

And Peter’s whining is really starting to get on my nerves.

The Plot: An explosion at a construction site occurs in Manhattan. The public is told that it was a gas main explosion, but that’s only part of the story. A 2 foot long metal egg-shaped cylinder was found in the rubble and it had apparently tunneled up to the surface from underground at high speeds and hit a gas main, causing the explosion.

Dunham and her team are called in. The object is moved to a warehouse command center, but Walter has it moved to his lab at Harvard. This turns out to be a good thing, because a thug wielding a futuristic weapon attacks the warehouse looking for the egg. Back at his lab, Walter wonders if the egg might be related to Project Thor, a plan he once worked on that featured an underground torpedo. When he and Peter hear about the warehouse attack, Walter decides to hide the egg. He sends Peter off on an errand, then sedates Astrid. He grabs the egg and flees.

Walter is eventually found hours later and tells Agent Dunham that he hid the egg, but doesn’t remember well. Meanwhile, the thug is still trying to find the egg. He abducts one of Dunham’s contacts and uses a through-the-nose mind reading machine on him. Later, he abducts Peter Bishop, uses the same machine on him, and discovers the location of the egg’s hiding place — even though Peter isn’t aware that he knows it. Dunham tracks Peter and the thug to the graveyard where the egg was hidden and guns down the thug during a chase. The egg burrows into the ground and disappears. Peter confronts a strange bald man who seems to be linked to the Pattern and has been observing events for years. He ends up on the losing side of this fight as well.

Not much to comment on science- and medicine-wise (except for the obviously ridiculous mind reading and “learning by osmosis” ideas). The rest is just nit-picks:

1. The Arrival
Sadly not related to the Charlie Sheen B-movie sci-fi flick The Arrival.
Which incidentally stars Ron Silver — who I have been reliably informed is actually a deadly assassin working for NASA. I expect this fact to show up in Fringe sooner or later.

2. Project Thor
Was the egg part of Project Thor or not?

3. Iridium
Iridium is a logical choice for a torpedo that travels through the earth as it is one of the most heat resistant metals known.
Solid Iridium is a yellowish-platinum color though, not indigo.
Astrid should have seen what was coming. Iridium is the second densest element, how was a tiny syringe going to penetrate it?

4. Mind Reading, take two
Enough with the mind-reading already — although the thug’s model appears to be an upgrade as it conveniently converts thoughts into sounds (though only mono). And uses an oscilloscope.

5. Osmosis Jones
Learning through osmosis and proximity? Nonesense. If that actually worked I would have aced every test in college and med school, and though it pains me to reveal this, I did not.
Reminds me a little too much of the discredited Hundredth Monkey Phenomenon.

6. The Observer
A bald guy who observes. Where have I seen that before?

Buzzy and Wolfie show up in yet another public service ad, this one from March 1951.

For those of you who may be unfamiliar with Buzzy, he was basically DC Comic’s answer to Archie, and he had his own comic from 1945 until 1951. He and his pal/rival Wolfie showed up in quite a few PSAs in other DC comics during that time — sort of a combination house ad/PSA. (It could be worse, at least Buzzy managed to steer clear of starring in over-the-top religious comics like Archie.)

This PSA was written by, of course, Jack Schiff. Art was handled by Win Mortimer, who also handled the art on some of the later Buzzy stories (and a few were written by Jack Schiff as well). This PSA was scanned from Action Comics #154 but can also be found is such comics as Detective Comics #169, Superboy #13 and Wonder Woman #46.

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Tags: comics psa buzzy wolfie handicapped jack schiff win mortimer

The top five Robert E. Howard characters, presented in order of preference.

1. Solomon Kane
A puritan who obsessively fights evil, armed with only a sword, musket, and his unwavering sense of righteousness. His stories tend toward a darker, grimmer view of the world. Kane has the best sense of style of any literary swordsman — I always played the Witch Hunter character in Warhammer Quest because he is clearly Solomon Kane. The best story is Red Shadows, where Kane travels the world tracking down the killer of a girl he never even knew. (Wikipedia link: Solomon Kane)

2. El Borak
Francis Xavier Gordon was a Texas gunfighter and adventurer who settled among the tribes of Afghanistan and had adventures among the deserts and mountains of Asia. Think Lawrence of Arabia combined with Captain Blood. The best story: Hawk of the Hills. (Wikipedia link: El Borak)

3. Kull
Not to be confused with Krull (and I like to forget the Kevin Sorbo movie ever happened). There were only a few Kull stories, but they were all good. The best: The Shadow Kingdom. (Wikipedia link: Kull)

4. Conan
The best known of Robert E. Howard’s characters. Truly, there have been some great Conan stories, but he also has his share of stories that are just okay, and that’s what marks him down in my eyes (and I’m only counting Howard’s stories; not the lesser Conan stories written by Lin Carter or Robert Jordan or others). My favorite: Red Nails. (Wikipedia link: Conan)

5. Bran Mak Morn
A darker series of tales. Bran Mak Morn is the last king of the Picts, a degenerate and dying race. The best story: Worms of the Earth. (Wikipedia link: Bran Mak Morn)

Solomon Kane	El Borak

Comics:
Most of these characters have appeared in comics at one time or another.
Solomon Kane appeared in an adaptation of Red Shadows in Marvel Premiere #33-34 in 1976, then had a six-issue mini-series from Marvel in the mid-eighties that featured adaptations of existing stories as well as new stories (and some nice Brett Blevins art). A new mini-series from Dark Horse has just started, and so far, seems good.
Conan has appeared in numerous comics published by Marvel and Dark Horse, the majority of which have been quite good.
Kull appeared in a handful of Marvel books in the ’70s and ’80s. I haven’t read them, so I can’t vouch for their quality. Dark Horse has a new Kull series coming out soon.
Bran Mak Morn appeared in several issues of the Savage Sword of Conan in the ’70s. Dark Horse published a two issue adaptation of Kings of the Night in the mid-’80s. It was not their best work.
To the best of my knowledge, El Borak has never appeared in the comics.

X-Men: Manifest Destiny #2 “Kill or Cure, part 2″
Mike Carey, writer
Michael Ryan, Penciler

Bobby Drake (Iceman) has been pushed out of an airplane by Mystique. He lands in a small mountain lake and drags himself to shore. A local sheriff finds him and brings him to the Emergency Room suffering from hypothermia.

ER Doctor: Nurse, prep me an IV drip and a hemodialysis filter. And bring some blankets and glucose gel.

ER Doctor: Okay, we’ve got to get that core temperature up, slow and steady. Wrap him up warm abd plug into the dialysis machine for an hour. Then we’ll see.
Nurse: Not looking good. Blood pressure’s way down. Brain activity close to coma levels.
Bobby Drake: Cold! Got to — cold –

1. First, let me start with the nurse’s comments. What the heck is she talking about in terms of “brain activity”? She’s not running any tests or an EEG to determine brain activity; she’s just checking his vital signs. Look at the scene: Bobby’s eyes are open, he’s gesturing, and he’s talking more or less appropriately, if hesitantly. That’s a Glasgow Coma Score of at least 11, nowhere near coma levels (which is 8 or lower).

Plus, if Bobby’s mental status is that bad, why is the doctor giving him glucose gel which he wouldn’t be able to swallow?

2. The doctor’s hypothermia treatment is appropriate, though I think he’s being overly aggressive. He is also overlooking a significant problem (see #3).

He is absolutely correct that the key to treating hypothermia is to rewarm the core temperature of the patient back to normal. How fast the patient should be rewarmed is still an area of some debate.

He seems to be treating Bobby as if he were a severely hypothermic patient, but the presentation doesn’t really support this. I’m sure that thanks to his Iceman powers, Bobby’s temperature is incredibly low and that’s throwing the doctor off, but he should also notice that Bobby is not demonstrating any of the other symptoms of severe hypothermia. For starters, he’s awake, breathing, and talking — all good signs. As my medical school instructors used to say, “Treat the patient, not the numbers.”

Blankets will help raise the temperature slightly (and so would putting some clothes on him), but warm packs would work even better. Heated IV fluids and warmed inhaled oxygen are other easy treatments. These will often be enough for the conscious, mildly hypothermic patients.

Patients with more severe hypothermia will likely require active core rewarming. Dialyisis (both hemodialysis and peritoneal dialysis) is one method of active rewarming and is a very effective method of raising a patient’s body temperature. Hemodialysis is a particularly good choice in cases where there is also kidney failure or electrolyte abnormalities. Neither of which seem to apply here, but there are times when you just have to go with whatever equipment is available. (On the other hand, it would be a very good idea to run some stat labs on Bobby.)

3. One last caution: hypothermic patients — particularly those who have been immersed in water (like Bobby) — the heart is very irritable and fatal heart rhythms are common. These patients should only be moved very cautiously and gingerly, and continuous heart monitoring is a must.

Detective Comics #849 “Heart of Hush, part 4 of 5: Scars”
Paul Dini, writer
Dustin Nguyen, penciler

This month’s issue of Detective Comics, which continues the story of Catwoman’s missing heart, answers some of the questions I raised last month, but leaves others unanswered.

1. The bizarre steampunk-ish machinery used to keep Catwoman alive without her heart is explained away as a machine designed by Mr. Freeze, utilizing his extensive knowledge of cryogenics. Her heart is kept alive in a similarly designed machine in Hush’s lair.
I consider that a reasonable explanation, at least from a comic-book-medicine point of view.
However:

It still doesn’t explain how Hush was able to transport that enormous piece of machinery — it takes up the better part of a large room — to Gotham General is a single ambulance.

There remains the problem of blood mixing with air; and random units of blood hanging from the machinery.

2. Hush explains that after his own run in with heart problems (thanks to the Joker), he “set about learning all I could about the heart — ways to remove it, restart it, test how long it could be kept alive outside the body…”
That’s as good an explanation as we’re probably going to get — and considering Hush is “The Best Neurosurgeon in World” — I’m willing to accept that he’s super-intelligent enough and driven enough to become “Darn Near the Best Cardiothoracic Surgeon in the World” in just a few months.

Apparently he’s also now “The Best Plastic Surgeon in the World”. Or at least “The Best Plastic Surgeon in the World who Operates on Himself.” (But remember the old adage: A Doctor who treats himself has a fool for a patient.)

3. It’s a shame that Dr. Mid-Nite and Mr. Terrific show up just to be stymied. What a waste of great characters.

4. Hush tells Batman that Joker triggered a massive heart attack. Unlikely. An aberrant pacemaker could trigger a fatal arrhythmia, but not a heart attack — that’s a flow problem, not an electrical one. (I go into this in more depth in a previous post about the topic.)

Eleventh Hour is yet another science/action/mystery show. This one is about the overly brilliant Dr. Jason Hood, biophysicist and “Special Science Advisor” to the FBI, along with Rachel, the attractive yet hard-as-nails FBI agent who accompanies him. Cloning is the subject of the first episode, as Jacob and Rachel hunt the mysterious Gepetto, a scientist who is trying to clone humans using innocent women as surrogate mothers.

The science is definitely better than Fringe, though the characters aren’t as interesting. The plot was compelling, despite a few plot holes (such as…how stupid is the surrogate mother not to realize something isn’t kosher? Or does she really think it is normal to have an obstetrical examination in an abandoned warehouse?)

1. Cloning
As Science not Fiction points out in their review, the science is reasonable, and the explanation of cloning given is fairly straight-forward and easy to understand. It’s easily the best depiction of cloning in a television show that I can recall.
For the record, the worst I can remember are the clone storylines in The Flash (Episode 18: Twin Streaks) and the live action The Amazing Spider-Man from the ’70s (Episode 5: Night of the Clones).
Why are the police running a DNA lab in a tent in the forest? It’s a delicate procedure and that’s just asking for contamination. (”The DNA appears to be half human and half oak. So let’s get the team out there looking for an Ent!”)

2. Placenta Previa
When the placenta covers the internal os (the opening between the uterus and birth canal), it is known as placenta previa. The condition is graded by how much of the os is covered. In Grade III placenta previa (mentioned on the show) — which is also known as partial placenta previa — the os is partially covered by the placenta. As you can imagine, this makes it a challenge to give birth vaginally. C-sections are the recommended delivery method in this situation*.

The classic symptom of placenta previa is painless vaginal bleeding during pregnancy, which is not what was shown on the show. Painful vaginal bleeding is more indicative of a placental abruption (when the placenta pulls away from the wall of the uterus), a much more dangerous condition**.

3. CPR
While I applaud the show for resisting the temptation to defibrillate a flatline, that has to be one of the worst examples of Hollywood CPR ever.

Television and movie CPR is almost always done incorrectly, with bent elbows instead of straight arms — but there’s a good reason for this because you don’t want to injure the actor portraying the victim. This scene was worse than that, with nearly everything done wrong, such as — in addition to the bent elbows — improperly placed hands, a patient who was up too high for good CPR, and too rapid a pace. In the end, to show he was really trying hard, Dr. Hood increased the speed of his compressions even more — but this is the worst thing he could have done. You have to give the heart time to fill with blood between compressions; faster compression means the heart doesn’t have time to fill, and the resulting CPR is worse, not better***.

Notes:
*Bear in mind that a placenta previa is fairly common in early pregnancy, and will usually shift away from the os as the uterus grows during pregnancy. So, delivery-wise, placenta previa is only a concern when it occurs late in pregnancy.

**Admittedly, placenta previa can sometimes stimulate premature contractions, which can be quite painful, but that doesn’t seem to be what was shown here.

***Though they saved the patient in this situation, it would not have worked like this in real life. She had flatlined because she had hemorrhaged and lost a tremendous amount of blood. Until that blood loss is corrected, it’s going to be impossible to get her heart restarted (especially with bad CPR).
Speaking of blood, why would there still be blood in a closed-down clinic?

Because if being forced to listen to Surfin’ Bird for several day straight doesn’t cause psychic damage, I don’t know what does.

Buzzy’s back for another public service ad, and if that isn’t enough to get you excited, it’s also another of the “Gee, isn’t school swell” DC comics was so fond of putting out in the 1950s and ’60s.

This PSA was written by Jack Schiff. Art once again by Win Mortimer, who as far as I can tell, drew all the Buzzy PSAs. This PSA was found in Action Comics #209, but can be found in other DC comics from October 1955 including Batman #97 (featuring “The Ballad of Batman and Robin”*), and Superman’s Pal Jimmy Olsen #8 (starring “Jimmy Olsen, Crooner” — maybe there’s a pattern here?).

* The words to the Ballad of Batman and Robin (at least according to the cover):

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Tags: comics psa buzzy school jack schiff win mortimer

Lots of 1 and 2 pointers this week, thanks to the mention of our old friends lupus and scleroderma. This week, Chris leads with 12 points, The Erskine follows with 6 points, and Ashtur, Dogma-Central, and GB all earned 5.

Overall, Ash remains the overall leader with 23 points. Estella remains in second, but creeps up to 19 points. The Erskine moves into third with 17, and Kevin Lighton drops to fourth with his 16 points, and George drops to fifth but gains at 13 points.

Full scores are available here.

An interesting mystery and clever solution weakened by a diagnosis that requires way too much coincidence and overlooking more obvious answers.

Nicole is a 25 year old Chinese woman raised in New Jersey who was given up for adoption as a young infant. She is back in China trying to find her birth parents. While in a temple there, she suffered a sudden attack of excruciating abdominal pain and started to vomit blood. By the time she has returned to the US and been admitted to Princeton Plainsboro, the Chinese surgeons have removed a foot of bowel.

The team’s initial suspicion is a Meckel’s diverticulum (a defect in the small intestine), so House performs an ultrasound which is negative. Nicole’s biological adoptive parents arrive with her medications from her apartment and tell House that they are saddened to discover Nicole has been drinking “again.” Looking though her medications, House finds the licorice root prescribed by the Chinese doctors and deduces that they suspected she had SARS (Severe Acute Respiratory Syndrome. Some researchers suspect that glycyrrhizin, a chemical found in licorice root, shows benefits in the treatment of SARS). She is placed in isolation and started on ribavirin and interferon (other medications that some research suggests may treat SARS). House is then is kidnapped by Wilson, with help from Cuddy, to guarantee that he will be present at his father’s funeral.

While Kutner is examining Nicole, she develops abdominal pain again and he notices that she is becoming tachycardic (has a faster than normal heart rate) and has signs of liver failure, meaning that SARS is the wrong diagnosis. She is scanned and a clot is found in her hepatic vein which Chase is able to remove surgically. The team discusses what caused her to clot. Thirteen suspects she has a genetic disorder that, when combined with her heavy smoking, makes her more likely to clot. The team decides to run further tests to determine which part of the clotting cascade is malfunctioning. When Kutner goes to draw her blood, he discovers Nicole is not in her room; he finds her outside the hospital, smoking. He draws the blood for the tests, but is unable to get her to stop bleeding afterward. Ultimately it takes 6 units of FFP (fresh frozen plasma — derived from human blood, it contains a high concentration of clotting factors) to get her to stop bleeding. This combination of clotting and bleeding causes the team to suspect that Nicole has DIC (disseminated intravascular coagulation), “which means cancer,” according to Kutner.

A CT scan is obtained and shows a large fluid filled cyst in the pancreas. The team is able to get House on the phone briefly, and he mentions something about a steamroller. Trying to understand his cryptic comment, they consider pancreatic cancer, scleroderma, lupus, gallstones, and a pancreatic divisum (a fairly common anatomical abnormality, it can sometimes cause chronic abdominal pain or pancreatitis). They decide that she has gallstones, which are confirmed on CT. They call in Chase to remove her gallbladder, but when he is talking to her about the planned surgery, he notices that her urine is dark brown (a sign of possible kidney failure). Thirteen recommends running a “bubble test” and injecting small bubbles of air into the pancreatic cyst to see if they travel anywhere else. House agrees; however, when they try to run the test, Nicole has delirium tremens (”the DTs”) so bad she cannot stop shaking. The team places her in a Phenobarbital coma to run the test and help her through DTs. The bubble test is negative, but Nicole is found to have dilated cardiomyopathy and a mass in her right atrium. The team suspects a myxoma (a benign tumor of the heart), but House believes it is iron overload (he suspects one or both of her parents have hemochromatosis). He wants to check an MRI, but he has a sudden revelation and stops Taub from running the test just in time. A simple x-ray of the head shows Nicole’s problem — nails in her brain. It seems her birth parents did not want her as a child and pushed iron nails into her brain through the fontanelles (the “soft spots”) in an attempt to kill her. When that didn’t work, her father secretly gave her up for adoption. She encountered a hidden magnet in the Chinese temple where her symptoms began — a magnet that moved a nail onto a section of the brain that stimulated abdominal pain. House stopped the MRI because the magnet in the machine would have ripped the nails through the brain. Though it’s not explicitly stated, the rest of her symptoms (basically everything but the abdominal pain) were caused by the iron overload (from the iron nails in her brain), which apparently hit full force at the precise moment the nail shifted. What a coincidence!

Major complaints are in red, minor in blue, nit-picking in green:

A diagnosis of DIC does not equal a diagnosis of cancer. There are many other causes of DIC including infection, trauma, major surgery, burns, obstetrical complications, liver disease, and heatstroke.
DIC causes clots in small blood vessels, not large ones like the hepatic vein.

Nicole had abdominal pain and was vomiting blood. Other than an occasional cough, what lung symptoms was she showing that caused the Chinese to treat her for SARS and House to mention the lungs as a source of her symptoms?

I’m suspicious of Thirteen’s “bubble test.” While there is a bubble test that can be used to find heart defects, it is only used on a relatively small single organ. Thirteen’s idea of trying to track microscopic bubbles wherever they may go over the entire body seems fruitless, especially when the overlying gastrointestinal tract is likely to have gas bubbles of its own. Plus this would only work if the cysts were connected.

Delirium tremens was only addressed superficially in the storyline. It is a life threatening condition, and tremors are only a small part of it. Nicole had the rapid heart rate and the tremors, but none of the other symptoms, so the diagnosis seems premature.
Phenobarbital is not the recommended treatment for delirium tremens; Benzodiazepines are. But then, House has made this mistake before.

Nicole’s symptoms didn’t really match Meckel’s, but then it’s a tricky diagnosis and hard to make. Usually it presents with rectal bleeding, and then a technetium scan is the best choice. In cases where there’s no bleeding, an Ultrasound is the best test.

What a pleasantly convenient finding that Nicole has a nail in the “addiction center” of the brain which explains away all of her bad habits.

CT scanners don’t beep when something weird shows up.

The medical mystery was fairly interesting, so earns a B. The final solution of the nails was clever and unexpected and is awarded a B. The medicine, while better than the past several weeks, relied way too heavily on coincidental timing — even for House – and only earns a B-. The non-medical soap opera aspects of this story were by far the best part, from Cuddy tranquilizing House, to the House/Wilson moments, to Hanson, and earns a solid A.

Last week’s House review
A list of all prior House reviews

A step backwards for Fringe this week with bad science and a cliched storyline familiar to anyone who reads comics (plot #124: character has electrical powers and unwittingly fries nearby electrical equipment).

The Plot: Joseph Meegar has been the unwitting victim of an experiment by an evil scientist that has turned him into an electrical generator. It’s not a power he can control — electronic equipment breaks when he his near, especially when he is upset. When he accidentally causes an elevator accident that kills 8 people, then mangles his boss, and then kills his mother, he decides to go on the run. Unfortunately, the evil scientist has caught up with him and kidnaps him. Luckily, Dr. Bishop is on the case and trains some carrier pigeons to track Joseph’s unique electromagnetic signature so that Olivia and the rest of the team can rescue him and arrest the evil scientist.

Electrical power and electricity are not areas I know a tremendous deal about, but even I could tell the science was fishy.

1. I Have the Power
That’s a rather selective power Joseph has. It fries the clock on his bed stand, but not the digital thermometer next to it? It fries his scanner and electronic pad at work, yet his Walkman continues to work?
Is Joe generating DC or AC? It would affect how his power would kill people and affect his mother’s pacemaker.

2. Tape It
I’m a child of the ’80s, and the original Walkman generation, and I can confidently tell you that a magnetic field does not permanently alter a cassette tape. The neat thing is you can record over things.

On to more biology and physics concerns:

3. What is the Source?
What is the biological source of his electricity? Generating enough electricity to levitate (let alone start parked cars and trucks) takes an incredibly amount of juice that needs to come from somewhere. And unless the efficiency is near perfect, he’s going to be generating a lot of heat as well.

4. A Weighty Problem
How can sensors determine the weight of the people aboard an elevator when it’’s in free fall?
Joe may have been “electrodynamically levitating”, but if so, he was just levitiating in relation to the frame of the elevator, not the outside world (or he would have hit his head against the ceiling). So even if he were levitating, he still would have borne the brunt of the crash.

5. Stop Motion
I liked the way the Astrid and the GPS said the birds had stopped, yet they were clearly still flying.
Are those poor birds going to be flying in circles for the rest of their life, or did Dr. Bishop reset their beaks?
I’ll grant you that Tesla coils look impressive, but I wouldn’t think they’re particularly good at imparting magnetic charges.

6. Matters of the Heart
Assuming the heart hadn’t already started to break down and decompose (with that “thermoelectric trauma” — a term that doesn’t show up in any medical literature search), how would a “residual electrical charge” cause it to beat normally when removed from the body? The heart’s electrical system doesn’t work like that; it requires specifically directed electrical stimulation, not an unexplained uniform “charge.”

Cardochine is one of those drugs that instantly causes a fatal heart attack. Like all the drugs in this class, it shares two characteristics:

It only exists in the world of comic books, television shows, and mystery novels.
A murderer who uses it is guaranteed to die from the same drug by the end of the story.

When aging stage actor Namus Shane tires of his current leading lady, he kills her with a dose of Cardochine and replaces her with a younger actress. He’s done this many times, and nobody seems to have any suspicions, even though Shane seems to be killing actresses left and right, sometimes two or three in the same week.

Luckily, the boyfriend of Kitty Martin — the young actress who Shane has his eye on as his next conquest — has appropriated some of the drugged wine that Shane uses and given it to his friend Bob Benton to evaluate. Bob Benton is not just the secret identity of the super-hero Black Terror, but he is also a super-pharmacist, able to dispense pharmaceutical knowledge faster than a speeding bullet.

Bob detects the deadly drug in the wine and suspects that Kitty will be its next victim. He changes into costume and confronts Shane at the theater. Trying to escape, Shane flees across the catwalk high over the stage, but slips and falls all the way to the ground. He manages to survive the fall, suffering just a mild concussion. A well-meaning stage hand rushes to his side and gives him a drink to revive him. Unfortunately, the drink he offers is the poisoned wine meant for Kitty, and Shane dies of a heart attack, a victim of his own drug (or maybe a victim of fatal irony, in comic books it’s sometimes hard to tell the difference).

Take Home Message: Don’t date younger actresses then try to kill them. Look both ways before crossing the catwalk. Don’t mess with drugs that cause instant fatal heart attacks because you’ll die of irony.

I will be attending Wizard World Texas, November 7th through 9th. In fact, I will be there in a semi-official capacity as one of the speakers at “Wizard World University” — a joint program sponsored by Wizard and the Institute For Comics Studies that looks at comics from an academic perspective. There will be four one-hour sessions, and I will be one of the speakers at the the second session: “Wizard World University: Comics Analysis”, Saturday from 1-2 PM.

If you’ll be attending the convention, stop by the session and say hello.

Congratulations to the Invincible Chris Sims, who, along with an assortment of other talented people, has started Action Age Comics. Given the previews he’s posted and images available on the Action Age site, it’s clear they will be producing comics I can fully endorse (there’s a pull quote you can use: “physician endorsed”).

(And, when you’re ready, we can talk about my magnum opus: Dr. Silverback, Gorilla M.D.
Slogan: “The 800-pound gorilla is back, and this time, he’s your doctor!”)

I am almost done with the annotations to Volume 1 of Black Jack and hope to have them posted by mid-morning tomorrow. That gives everyone enough time to finish reading the book, or to go out and buy and then finish reading it (you have picked it up, haven’t you?).

I am particularly interested to see what people thought of the sixth story, “Confluence” (the one about Black Jack’s true love).

Black Jack is a famous manga character written by Osamu Tezuka. He is a supremely skilled surgeon, though an unlicensed one. Often he is the only surgeon skilled enough — or even willing to — perform a particular lifesaving operation. He will operate on the rich and the poor alike, and lives by his own code of ethics.

Tezuka was a medical school graduate and did his best to add medical accuracy to his stories, though he never let that stand in the way of a good plot — you’ll notice that many of the stories contain implausible fantasy or science-fiction elements. The stories were published over a ten-year period, from 1973-1983, so it’s also important to remember that they were written 20-30 years ago and medicine has come a long way in that period of time. There is sometimes a difference in the approach to certain patients and conditions between Western and Eastern medicine, and that occasionally shows up in the stories as well.

Vertical has recently started releasing a very nice collection of Black Jack stories. These volumes present the stories chronologically as they occur in Black Jack’s life. (This is different than the order in which the stories were originally published). My copy of Black Jack: Volume 1 is the limited edition hardbound and the pages references below match that edition. Hopefully, the pages numbers are the same in the softcover edition as well.

In my annotations below, I’ve added the year the story was first published. Consider this a strong Spoiler Warning as well. Click “Read More” to read the rest of the post.

With both Halloween and United Nations Day just around the corner, this seemed the perfect time to let Superman teach us about “Pennies for UNICEF!” In this public service ad, Superman flies a couple of American children around the world just so that they can see where the money they collect is going.

After “Stay in School,” I think the United Nations was the second most common topic among DC comics PSAs. Of course, they were written in an era when the United States had more power and prestige in the UN, and, frankly, held the institution in higher esteem. I doubt you’d see a similar PSA written today.

Does UNICEF still collect pennies at Halloween? We get plenty of trick-or-treaters but I haven’t seen one of the orange collection boxes in years.

This public service ad was popular enough to run twice, in the DC comics of 1962 and 1966. This particular copy was scanned in from The Brave and the Bold #45 (December 1962). The script was written by Jack Schiff with art by Sheldon Moldoff.

This week’s episode of House was definitely a character episode focusing on Dr. Hadley (Dr. Thirteen, that is), and it showed in the jumbled mess that was made of the medicine.

Dr. Thirteen picked up Spencer, a girl at a local bar, and brought her back to her apartment for a night of casual sex. As she is washing up afterward, she looks up to see her companion fall off the bed in a tonic clonic seizure. Spencer is rushed to the hospital (Princeton Plainsboro, of course), and admitted to House’s team.

This is Spencer’s first seizure, but her medical history is also significant for several months of severe fatigue as well as a retinal vein occlusion (a blockage in one of the veins of the eye — very unusual in someone of her age) that happened several years ago. The initial differential includes dehydration, drug abuse, some vague neurological problem, or a blood problem. Kutner and Taub suspects blood clots, which they blame on her bone marrow being in “overdrive” and producing too many platelets. Instead of going about it the easy way and checking a blood count — which includes a platelet count — House orders a bone marrow biopsy. Thirteen performs the biopsy, an extremely painful procedure, but the results are normal.

Later as Spencer is being discharged, she starts gasping and the heart monitor shows tachycardia (a rapid heart rate), which ultimately needs defibrillation to control. Drug abuse is the top potential diagnosis again, and House and Foreman search Thirteen’s apartment looking for clues. They find a brown recluse spider, so a spider bite is now a possibility as well. House orders Thirteen to perform a thorough search of Spencer for a spider bite. She finds no bite, but discovers that Spencer has numbness in the skin over her hip. Labs reveal hypokalemia (a low potassium level), which Thirteen believes explains the numbness and heart problem. House tells her that the low potassium indicates a kidney disease. IgA Nephropathy, PSAGN (post sterptococcal acute glomerulonephritis, i.e. kidney damage following a Strep infection), and Renal Tubular Acidosis (RTA) are all suggested, but RTA is the only one House thinks fits (RTA occurs when the kidney don’t acidify the urine like they should and acid builds up elsewhere in the body. There are several types; House is referring to Type I, or distal, RTA). He orders a CT of the kidneys to look for kidney calcifications, a sign of Type I RTA.

The CT must have been positive, because when we next see Spencer, she is in surgery having kidney calcifications removed. As the operation is ending, her oxygen saturation (the percentage of red blood cells in the arteries that are loaded with oxygen) starts to drop precipitously and she requires intubation. A chest x-ray shows normal lungs so the team suspects she suffered some sort of airway collapse, possibly from an autoimmune disease or some form of dystrophy. House has them place her on a treadmill and perform a methacholine challenge (a medication that causes airway narrowing; used to diagnose asthma) to see if they can induce the airway collapse again so they can diagnose it. Meanwhile, Thirteen is re-examining the x-rays and sees some subtle signs of a flattened diaphragm (a sign that the lung in question in over-inflated), which she interprets to indicate a lung cyst. She rushes to catch up with the rest of the team because she believes placing Spencer on a treadmill will cause her lungs to “explode.”

Thirteen was correct. When she arrives, Spencer is on the ground grasping for breath. Thirteen notes the deviated trachea and realizes Spencer has a tension pneumothorax (from a ruptured lung cyst) and performs a needle thoracostomy to correct the problem. The team obtains a chest CT which shows many other lung cysts. The differential now consists of amyloidosis and pulmonary fibrosis. A cyst is biopsied and shows smooth muscle cells. This is a sign of LAM (lymphangioleiomyomatosis), a progressive and fatal lung disease. When Thirteen breaks the news to Spencer, she notices Spencer is bleeding. A blood count is completely low, which doesn’t fit with LAM. The differential now shifts to include aplastic anemia (the bone marrow stops producing any blood cells), PNH (paroxysmal nocturnal hemoglobinuria), Langerhans Cell Histiocytosis, or mastocytosis. House wants to perform a bone marrow transplant, without killing off Spencer’s own bone marrow first — a definite initiation for graft versus host disease. During a conversation with Thirteen after she gets the consent, he has his weekly “Eureka” moment. Seeing Thirteen chapped lips, he realized that Spencer also has chapped lips; he then realizes that Spencer has never cried, even when told she was going to die, and even when he purposefully exposes her to freshly cut onions. Malfunctioning tear ducts are one of the classic signs of Sjogren’s Syndrome, a type of autoimmune disease. With treatment, Spencer will recover.

Major complaints are in red, minor in blue, nit-picking in green:

While Sjogren’s can be associated with lung cysts, that does not explain away the lung biopsy showing smooth muscle proliferation.

It’s sad when a team of alleged medical geniuses can’t diagnose a tension pneumothorax.
On the other hand, if the pneumothorax is severe enough to cause tracheal deviation and pulmonary collapse, why are there breath sounds? (But then Taub’s a plastic surgeon, maybe he forgot how to use a stethoscope).

What explains the seizure that started the whole episode?

Going straight to bone marrow biopsy is a bad idea. And then forgetting it was normal when discussing all the bone-marrow-influencing diseases later in the episode (aplastic anemia, PNH, etc).

Bone marrow transplant? That came out of nowhere with no supporting diagnosis to explain it, especially the way he wants it done. Remember, her bone marrow biopsy was completely normal at the beginning of the hour.

Kutner and Taub’s “blood clots” diagnosis doesn’t explain anything, except maybe the retinal vein occlusion.

Recent studies show LAM is not as rapidly fatal as initially believed, with many patients living 20+ years after diagnosis.

All that kissing and Thirteen never noticed that Spencer had a severely dry mouth (and would be dry in other significant areas as well).

Brown Recluse Spider bites are hard to miss.

Lung cysts usually show up on x-rays

If Thirteen were properly using a spacer with her steroid inhaler, she wouldn’t have the chapped lips.

The medical mystery was pedestrian (at least by House’s standards), so earns a C-. The final solution of the Sjogren’s is something they should have caught sooner, and contradicts some of the early data. It leaves some important findings unexplained as well. I give it another C-. The medicine was disorganized and all over the place and skipped straight to the zebras, skipping the more common diagnoses and proper tests. It earns a measly D. The non-medical soap opera aspects of this story were good if a little predictable (who couldn’t see that Wilson was stringing House along) and earns a B+.

Last week’s House review
A list of all prior House reviews

Congratulations to JockM, who was the only player to score in the double digits this week (actually, he was the only player to earn more than 3 points).

Overall, Ash retains the lead with 24 points. Estella remains in second with 19 points. The Erskine, Kevin Lighton, and JockM are all tied for third with 17 points.

Full scores are available here.

I thought the flow of the action was better on this episode of Fringe, but the medicine and science (and science-fiction clichés) were laughable.

The Plot: At night, an unmarked van pulls into a deserted street and people in some sort of containment suits drop off a confused woman named Emily. The woman wanders into a nearby diner and a friendly waiter and cop strike up a conversation with her. She is partially amnestic and claims she was given red and blue medications. Suddenly, everyone in the diner starts screaming in pain and they start bleeding out of their eyes. The young woman tries to escape, but her head explodes.

Agent Dunham and her team are called in to the diner. They discover that Emily had a rare autoimmune disease Bellini’s Lymphocemia and she had been missing for 2 weeks. The FBI also gets information that Claire, another young woman with Bellini’s Lymphocemia, has also gone missing. The team is able to discover that both Emily and Claire were receiving experimental treatment for their disease with capsules of Strontium-90, a radioactive isotope. Walter realized that in Emily, for some reason, all the capsules detonated at once, releasing an incredible microwave beam and essentially cooking everyone in the diner alive.

Agent Dunham discovers that Intrepus, an unethical pharmaceutical company (cliché plot device #37) is involved. Peter Bishop is able to discover the location of their secret lab. The FBI goes in guns blazing with a heavily armed SWAT team (except Agent Dunham, who apparently thinks it’s casual day at the raid) and rescues Clair, just in time, and did I mention that Walter was able to synthesize an antidote?

1. Autoimmune Insanity
Bellini Lymphocemia is a fictitious autoimmune disease. First off, lymphocemia is not even a real word, or a medical term, for that matter. It is said to be incurable — but then the vast majority (if not all) autoimmune diseases are — but for some reason, Bellini’s goes into remission with radiation treatment.
Strontium-90 does have various medical uses, including the treatment of some cancers (though it can cause cancers as well).

2. Needs Protection
When doing the autopsy, Walter should be wearing some form of containment suit. As far as he knows at that point, there are high levels of radiation as well as the possibility of an infectious disease.

3. Radiation versus Microwaves
Why would a radioactive isotope release high levels of microwaves? They are at opposite end of the electromagnetic spectrum. And conversely, why would a microwave exposure leave residual radiation?

4. Smells Like Cloves
Methyleugenol is not blue, it’s pale yellow. It is one of the main chemicals involved in the hyacinth scent, but it’s found in many other plants as well. It always smelled like a milder sweeter clove-scent to me.

5. My Eyes Have Seen the Glory
How does exposing people to high levels of microwaves (or high levels of radiation) cause them to bleed out of their eyes? I would expect burns, or if the all the water in their body suddenly boiled, I would expect ruptured eyes or other organs, not just bleeding
None of this explains why Emily’s head exploded though.

6. Self-Contradicting Statement of the Week
“Subcutaneous injection marks: she was being given medicine intravenously.”
Emphasis mine. Subcutaneous and intravenous are two different ways of giving medication.

While not as common as the classic psychic nose bleed, the magic-related nosebleed shows up from time to time. This is at least its third appearance in Rex Mundi.

In this scene, Lady Isabelle is using her powers to defeat a cadre of her father’s soldiers.

Her plan works, sort of…

Continuing my medical annotations of Volume 1 of Black Jack, by Osamu Tezuka, and published by Vertical. This post looks at the six stories that make up the second half of the volume, plus the story “The Two Jans” which is found in the hardcover edition only.

Several of my favorite stories in this volume will be covered in this post. I was particularly fond of “Star, Magnitude Six,” “The Legs Of An Ant,” and “Two Loves.”

There are mild spoiler warnings for this post, but not as significant as part one of the annotations. Click on “Read More” to view the rest of the post.

Read more…

Today marks the 150th anniversary of the birth of America’s most badass president, Theodore (Teddy) Roosevelt. And what better way to commemorate the day than with a DC Comics public service ad about the man himself?

This PSA appeared in a variety of DC’s November 1957 comics, including Action Comics #234 (the source of this scan), Adventure Comics #242, World’s Finest #91, and Wonder Woman #94.

The script for this PSA was by Jack Schiff, with pencils by Ruben Moreira. Unlike some other patriotic PSAs, this one was only published that one month — probably because it specifically mentions celebrating the centennial of Roosevelt’s birthday, which would limit its use in later years.

Theodore Roosevelt biography at WhiteHouse.gov
Theodore Roosevelt article at Wikipedia
The National Portrait Gallery/Smithsonian biography of Theodore Roosevelt
Text of Teddy Roosevelt’s Inaugural Address (March 4, 1905)

The high scores this week went to Miliardo and Trina W. who both scored 12 points.

Overall, Ash remains in the lead and gained a point for a total of 26 points. Estella remains in second with 19 points. The Erskine takes sole control of third with 18 points. Kevin Lighton and JockM are tied for fourth with 17 points.

Full scores are available here.

An interesting medical mystery on this week’s House, unfortunately bogged down with a solution that makes no sense. Meanwhile Cuddy is having problems of her own.

There were two medical stories on tonight’s episode of House. I will look at them each in turn.

Jerry Harmon, a 37 year old single father, is admitted to House’s service for evaluation of recurring blackouts, some lasting as long as nine hours. He has also been experiencing hallucinations. A prior work-up including an EEG and CT scan have ruled out drugs, alcohol, and epilepsy. The team’s initial differential diagnosis consists of post-concussion syndrome, TIA (transient ischemic attack, i.e. “mini-stroke”), toxins, or cavernous sinus thrombosis. An examination of Harmon’s strangely plain house also adds the possibility of a mold exposure.

The team later encounters Harmon in the hospital elevator where he ignores the doctors and makes some cryptic remarks about an appointment. They quickly realize he is sleepwalking. The differential diagnosis now consists of stress induced insomnia, narcolepsy, or a toxic exposure. House suggests that the team let him sleepwalk again and follow him to his “appointment” because it might provide more clues. Taub and Thirteen do just that and follow as Harmon climbs into his car and drives downtown to buy some cocaine, all while sleepwalking. The team now suspects that the cocaine may be causing the problems in a sort of vicious cycle (cocaine use leads to insomnia which leads to sleepwalking which leads to buying more cocaine, etc.), or possibly it is whatever the cocaine is cut with that is causing the problem. Taub and Thirteen buy some cocaine from the same dealer and find that lactose powder has been added to the cocaine. The team concludes that a lactose allergy may be causing the symptoms.

As Taub is giving Harmon a final exam he discovers that Harmon is sweating blood, and this rules out both a cocaine-induced or milk-induced cause. The team now considers a hemorrhagic fever (an infection like Ebola), DIC (disseminated intravascular coagulation), or leukemia. They all seem unlikely possibilities, but House is intrigued by the leukemia diagnosis, so orders a bone marrow biopsy. During the biopsy, Taub notices that Harmon has unusually dark skin (”bronze skin“)and this leads him to run some tests which show that Harmon is in severe kidney failure and in need of a kidney transplant. The differential now consists of hemochromatosis, vasculitis, or scleroderma. When talking to Harmon’s daughter about the possibility of donating a kidney to her father, House notices that she too is sleepwalking (or sleep talking, as the case may be). Soon she starts sweating blood. This means that whatever is affecting Harmon is affecting his daughter as well. The team comes up with three possibilities: it could be an infection, or a toxin (though tests have pretty much ruled those two out) or it could be an inherited condition, of which there are dozens to test. During a conversation with Wilson a short time later, House has his “Eureka” moment as he realizes that both father and daughter are anhedonic (they have the inability to feel happiness or joy). Foreman suggest this could be due to schizophrenia and Thirteen suggests depression, but under House’s questioning, Jerry Harmon admits that his name is really Jamal Hamoud and he is of middle eastern descent. He and his daughter have Familial Mediterranean Fever. Some colchicine and anti-inflammatory medication and they should be better.

Cuddy is excited because she will soon be adopting a baby girl who is due in 2 weeks. She meets Becca, the mother, at a local restaurant and notices a lacy rash on her left forearm. Concerned that it might be Fifth Disease (a viral infection which can be passed from mother to child and cause developmental problems, but only earlier in the pregnancy), Cuddy brings Becca to the ER for evaluation. Cameron examines her and doesn’t think it is Fifth Disease, and the labs support her. Cuddy decides to admit Becca anyway. An ultrasound reveals that the baby’s lungs are not fully developed yet. Cuddy orders steroids to help the baby’s lungs develop quicker, and magnesium to prevent any contractions. A little while later, as Cuddy is explaining things to Becca, she notices that Becca’s heart rate is accelerating and there is what appears to be vaginal bleeding. It is later confirmed that Becca has a grade II placental abruption (the placenta is pulling away from the uterus, causing bleeding. This can be fatal for the baby, who requires the placenta to live, and the blood loss can be devastating to the mother as well).

Cuddy is now faced with hard choice: deliver the baby now (better for the mother, riskier for the baby due to the under-developed lungs), or wait for a week or more (better for the baby’s lungs, but a higher risk for bleeding). She recommends waiting (but it is not clear whether it is Cuddy-the-doctor, or Cuddy-the-mom-to-be talking), but Becca is scared and elects to deliver the baby now. Chase is called in the baby is delivered by c-section. There are some tense moments after delivery, but eventually the baby starts crying and does very well. Everything seems to be moving towards a nice happy ending, but then Becca decides that she wants to keep the baby after all, leaving an emotional distraught Cuddy.

Major complaints are in red, minor in blue, nit-picking in green:

The case presentations and symptoms don’t match Family Mediterranean Fever at all (for instance, there’s a reason it’s called a fever). FMF is marked by recurrent bouts of severe inflammation including fever, joint pain, and abdominal pain that last a few days at a time. Rashes are common as well. Anhedonia can (rarely, very rarely) occur. The patients were showing no symptoms of inflammation. The medications given by House treat the attacks of inflammation only and would not have corrected the anhedonia.

Magnesium Sulfate is not a good drug for stopping premature contractions; recent studies show it is no better than placebo and it can have significant side effects.
Why give Becca a drug to stop contractions when she’s not having any? All tocolytics (drugs that stop contractions), especially magnesium, carry risks.

The most common cause of anhedonia is not schizophrenia, but depression. It’s not a common symptom of schizophrenia at all.

After 2 doses of betamethasone (a steroid) and 24-48 hours, the baby’s lungs will show significant improvement. The preferred treatment in this case would be to wait forty-eight hours (not two weeks) while carefully watching mom and the baby and then carry out the c-section. Cuddy may not have been able to talk Becca into 1-2 weeks of waiting, but 1-2 days would be a good compromise.

Classically, placental abruption is marked by painful vaginal bleeding. Painless vaginal bleeding is more likely a placenta previa.
Cameron should have caught the abruption on the ultrasound.
What is Cameron doing on the OB floor doing the U/S anyway?

Fifth disease has other prominent symptoms: bright red cheeks (hence its other common name “slapped cheek disease”) and bad cold symptoms, usually with a fever. These symptoms all occur a day or two before the lacy rash. Surely Becca would have noticed these (though admittedly the symptoms are worse in children). Fifth disease can cross the placenta and cause birth defects but only much earlier in the pregnancy.

This show loves to throw around fancy medical terms without any explanation. Why then does Taub use the vague term “mini-stroke” instead of the proper medical teram TIA? No doctor, especially one on House’s team, would ever do that. (I’d make another joke about plastic surgeons, but I think I’ve beat that dead horse enough).

There may not be any postpartum depression, but post-adoption depression is quite common.

This is another case where a good physical exam on admission would have caught the significant symptoms earlier (bronze skin in this case).

C-sections are performed by obstetricians, not surgeons. Or is Chase an OB too now?

The medical mystery had some interesting symptoms and lots of potential, so gets a B+, but unfortunately it was squandered potential and the final solution only deserves a D. The medicine, while less hap-hazard than last week, still left large parts out (suddenly he needs a transplant because of kidney failure? from bronze legs?) and earns a C. The obstetric medicine was equally mediocre and shares that grade. The soap opera was good, if depressing (and tantalizing, I guess, at the end), but we needed more Wilson: B+.

Last week’s House review
A list of all prior House reviews

Internet stalwarts Kevin and Mike have made clear their opposition to Marvel’s use of the term “Rulk” for the new Red Hulk. But I, on the other hand, enthusiastically welcome the idea. No longer do we have to go through the arduous task of memorizing two words when one word will do. And forget about having to pronounce all those extra syllables, now you don’t have to!

I like the idea so much, I think Marvel should extend it to all their color-themed heroes and villains:

In fact, I think DC should copy the idea and use it themselves:

Not to mention Kirby’s own Blacer, just to name a few. Think of all the saving in time, effort, and lettering!