Polite Dissent

Miss Sinister daintily wipes the blood from her nose after a failed attempt at breaking Daken’s mental barriers in X-Men Legacy #217 (Mike Carey, Scot Eaton).

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Tags: comics medicine nosebleed x-men miss sinister

Since tomorrow is election day, I thought this would be a perfect public service ad for the week. I know I’ve run it before — last election day, if memory serves — but I felt it was apropos for tomorrow, especially since one candidate in particular seems a little unclear on that whole first amendment/free speech issue.

Click on the image for the full PSA

Written by Jack Schiff with art by Win Mortimer, this PSA was originally published in January 1953 DC comics including Action Comics #176, Wonder Woman #57, and World’s Finest #62. As was the case with many DC comics PSAs, it was later republished in July 1960 in a such comics as Detective Comics #281, Superboy #82, and Superman’s Girl Friend Lois Lane #18 (where this copy is from).

Other Patriotic PSAs (more or less):
The U.S. Constitution (straightforward PSA about the Constitution)
Airboy and the Constitution (Free Speech and schools, from Airboy )
Are You a Red Dupe? (1950s anti-communist screed)

scene from Marvel Apes #1

There’s a Reed Richards fellowship for über-doctors. No wonder there’s so many of them!

A quick reminder that I will be at Wizard World Texas this weekend. The panel I am participating in is at 1PM on Saturday. Stop by if you can!

Another quick note: Pick up and/or read Terra #1, out this week. Dr. Mid-Nite makes a couple of very interesting comments in the final pages I’d like to discuss. Plus it’s features Amanda Connor art.

Some interesting points in a couple of throwaway lines by Dr Mid-Nite in the recent Terra #1.

I. “Regular physicians don’t know how to store and maintain metahuman blood.”
I had not realized that metahuman blood required any different storage than normal blood, and I don’t recall this little tidbit having been mentioned before (so I guess that makes me just a “regular doctor”).
It raises some questions:

• Does metahuman blood require special care because it’s more fragile?
• By metahuman, does Mid-Nite mean any super-hero’s blood (including aliens, magical beings, etc), or specifically those with the metagene?
• Can metahumans donate blood to other metahumans? Or only to themselves? Or maybe to other metahumans with a similar power set*?

II. Dr. Mid-Nite then makes a somewhat wordy and not-entirely clear statement about transfusions, which seems to imply that metahumans essentially have a different blood type than non-metahumans.

There are over two-dozen different human blood type proteins. Most of these are minor proteins and don’t have much, if any, affect on medical care. However, there are two that are very important: the ABO and Rhesus (Rh) proteins; these are the two that make up the commonly understood definition of blood type (e.g. A+, O-, AB-, etc.). If there is a transfusion reaction due to blood cell compatibility, it will be because of a mismatch in one of these proteins.

It could be that the “blood type” that Dr. Mid-Nite refers to is one of the minor blood type proteins. In that case, the “blood type” is more of academic interest, and doesn’t affect medical care. On the other hand, Mid-Nite’s specifically mentions transfusions, which makes me think it is more similar to the ABO or Rh system, and that makes me wonder why it has never been mentioned before.

• Wouldn’t it be relatively easy to test for these blood cell proteins to determine if someone is metahuman, as opposed to testing for the gene, which seems to be the current technique?

*This similar-powers-required-for-transfusion idea has surfaced the most often in Jay Faerber’s corner of the Image universe. First, there was Firebird-lite donating blood to Firebird, (though admittedly they’re related), and then more recently in Noble Causes, when the team went looking for individuals with ice powers to provide blood for the injured Frost.

In celebration of Veterans Day, here is a public service announcement from General Henry “Hap” Arnold — then leader of the United States Army Air Forces, and later to become one of the proponents and leaders of an independent United States Air Force. It’s a great ad because it stresses the importance of education and intelligence in leading the military, if not the nation itself — concepts which seem to have become unimportant, if not outright derided, of late.

This PSA appeared in Captain America Comics #43 (December 1944)

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The high score this episode was 17 points, earned by both Mathew and Sable Hope.

That was enough to jump Sable Hope into first with a total of 27 points. Ash is bumped down to second, which he shares with JockM, with 26 points. Tied for fourth with 19 points are Dogma-Central, Estella, and The Erskine with 19 points.

Full scores are available here.

Tonight’s episode of House was fairly light on actual medicine, focusing more on the personal aspects. Though there wasn’t much, for the most part, the medicine was well done.

Stewart is a thirty-five year old man with severe agoraphobia — he has not left his house since a mugging seven years before. Cameron stopped by and helped him with a case of the flu the previous year, and it is brought to her attention that he has had several days of a crushing headache as well as 3 seizures in the past 2 days; she in turn brings it to House’s attention. The initial concerns are a bleed, a clot, a tumor, a metabolic disease, or an infection (though they also mention vasculitis, which doesn’t fit in any of those categories). Since he refuses to leave the house, the team has to diagnose him with whatever they can bring to his house. The preliminary plan is to run an EEG while inducing a seizure to see if that will suggest where the problem in the brain is located. While Cameron runs that test, the rest of the team will search the house for toxins. At the end of the day, both the search of the house and the attempt to cause a seizure are fruitless.

House now decides to induce a seizure his own way, by bringing the outside world to Stewart. He pretends Stewart’s house is up for foreclosure and brings a passel of potential buyers through the house and into Stewart’s bedroom. Stewart immediately reacts, but the EEG reveals it’s not a seizure; instead he’s having severe abdominal pain caused by a partial small bowel obstruction (diagnosed by portable x-ray). Atrial fibrillation and Crohn’s Disease are mentioned as possible causes. House thinks surgery is the best option, but Stewart still refuses to leave his home. So they tell him that they will perform the surgery at his house, but plan on sneaking him to the hospital for the actual surgery, then returning him home before he awakens. Cuddy learns of the plan and insists that Stewart remain in the hospital for recovery; House agrees. Cameron decides it would be best to let Stewart know of the plan and wakes him from anesthesia to tell him that he’ll have to stay at the hospital. Surprising no one (except maybe Cameron) this causes him to freak out, and not only does he decide leave the hospital before having the surgery, but he gets a lawyer involved.

Cuddy responds by kicking Cameron, House, and Chase off the case, but since when has that stopped them? House has Cameron try some lactulose (a potent laxative) on Stewart, but his symptoms worsen. House now decides that they’re going to have to proceed with surgery, and actually perform it at Stewart’s house. Taub is roped into the job. The bowel obstruction is relieved and a bowel biopsy obtained, but not before there’s a little accident involving cautery, bowel gas, and fire. The biopsy shows flattened villi (tiny finger-like projections from the inner lining of the small intestine), which suggests Whipple’s Disease (a rare gastrointestinal infection), so House starts Stewart on antibiotics.

Stewart’s symptoms don’t improve, and in fact they worsen: he begins to develop numbness of his legs. The differential diagnosis now consists of porphyria, amyloidosis, and celiac sprue (an autoimmune disease caused by exposure to the wheat protein glutein in certain individuals), with sprue the most likely. This can be diagnosed by a blood test, but House prefers to feed Stewart wheat so that his symptoms will worsen and he’ll voluntarily decide to come to the hospital. He stops by Stewart’s house late at night to check on him, and Stewart happens to go into cardiac arrest at that moment. House views this as a chance to admit him to the hospital (it being an emergency and all), but Cameron shocks his heart back into a normal — albeit dangerously slow — rhythm. Taub sets up an external pacemaker to control the heart beat. The differential now consists of lymphoma or a toxic exposure, possibly organophosphates (a common chemical in insecticides). House then discovers that Stewart is something of a neatnik, and cleans his bathtub frequently with ammonia and bleach, which when combined, release chlorine gas. Could his symptoms all be due to chlorine gas poisoning? Stewart is started on steroids and sodium bicarbonate, but his symptoms continue to worsen. During a conversation with Cameron, House deduces that Stewart’s symptoms are not caused by chlorine gas, but instead all due to lead poisoning. When he was shot during the mugging several years before, the bullet split and some of the fragments remained in Stewart, embedded in the hip bone. As these slowly dissolved, the lead was enough to cause his symptoms. House quickly, and brutally, removes the fragments, and Cameron starts him on chelation.

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

Defribillation is not the treatment for a flatline. In fact, it is thought to make things worse (How can it be worse than a flatline, you ask? By making it even harder to get a normal rhythm back.)

Stewart suffered a cardiac arrest, not a heart attack. The two terms are not interchangeable.

House told the ambulance it was PEA (pulseless electrical activity), but the heart monitor showed a flatline, not PEA. Anyway, you don’t defibrillate PEA either.

I find it hard to believe that bullet fragments significant enough to cause Stewart’s symptoms would be missed on the x-ray. Hint: the hip should have no bright white spots on the x-ray. I also find it quite a stretch that bullet fragments in for seven years could be removed so easily.

Chlorine gas is extremely irritating (watery eyes, cough, sore throat), and would be hard for him to miss being exposed.

Why did Stewart need a jugular line?

Surgery is not first line for partial small bowel obstruction.

Wouldn’t Stewart be suspicious that there was no anesthetist or anesthesiologist? And once again, no eye protection during the surgery.

There’s no way Kutner made it though medical school without assisting in surgery. A large part of the third year is spent doing just what Kutner said he didn’t know how to do: retracting and keeping the field bloodless.

The medical mystery itself was rather pedestrian (for House, anyway), it was just the restrictions that made it challenging — I give it a C+. The final solution fit well, but was it ever mentioned before the final reveal that Stewart had been shot? I give it an A-. The medicine actually followed a more-or-less logical progression this week, though shocking a flatline is big mistake in my book, no knocks the score down to a B-. The soap opera aspects were all well done, particularly the Chase/Cameron aspect: another A-.

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

An international thriller, with little thrills, along with bad science, atrocious medicine, and plot holes you could drive a truck through. It must be another episode of Fringe!

The Plot:An FBI agent recently back from a mission to Germany falls suddenly ill and is found to have a large parasite of some sort wrapped around his heart. Dr. Bishop gets a tissue sample from the parasite, and its DNA sequence suggests it is tied to an organization known as ZFT. This leads Agent Dunham to Germany to quiz a prisoner by the name of David Jones about the parasite. Jones will cooperate, but only if he can talk with his compatriot Joseph Smith back in the U.S. Unfortunately, Mr. Smith was just shot and killed in an FBI raid. This doesn’t deter Dr. Bishop, who hooks the recently deceased Mr. Smith up to one of his machines so that Peter can act as an intermediary and read his brain (with a little help from high voltages of electricity). The plan works and they are able to convince Mr. Jones that he is in contact with Mr. Smith, and he gives the cure for the parasite. Loeb is saved, but surprising no one, except the supposedly very smart characters on the show, seems to be involved in “The Pattern” himself.

1. The Heart of the Matter
The emergency department doctors defibrillate Mr. Loeb when he is in asystole. Asystole is the medical term for flatline, and as we all know, you don’t shock a flatline.
Later, when Loeb is in ventricular fibrillation, one shock is tried (along with a dose of epinephrine a few minutes before). When that doesn’t work, the doctor decides to crack Loeb’s chest open and perform open heart massage. That procedure, though dramatic — and it did reveal the parasite — is rarely called for, and certainly not this early in the resuscitation (and not for ventricular fibrillation). The doctor took his own sweet time opening the chest too; it would have been nice if someone had done some chest compressions in the meantime.

2. There’s an Intestinal Parasite in His Chest?
It’s a huge jump from a simple parasite like Giardia to a giant-centipede-looking-plant-like parasite wrapped around the heart, but I guess that’s just Dr. Bishop’s way of thinking.

3. Relax, part 1
When the parasite starts squeezing harder, Peter injects Loeb with some cyclobenzaprine. Cyclobenzaprine is better known as Flexeril and is a skeletal muscle relaxant used for muscle spasms such as whiplash injuries. It doesn’t have an effect on the heart, so I’m assuming Peter was giving it to Loeb assuming it would be absorbed by the parasite and cause it to relax its grip on the heart. That’s quite a jump in logic: that a moderately strong (at best) mammalian muscle relaxant would affect a giant-centipede-looking-plant-like parasite.

4. Relax, Part 2
If I were Peter, I would definitely want a sedative. He recovered remarkably quickly, though.

5. Needle in the Heart
Sticking a syringe full of adrenalin blindly into the heart is a very bad idea because of the risk of injuring a cardiac artery, but I guess that’s just Dr. Bishop’s way of thinking. Or maybe he watched Pulp Fiction too many times at the asylum.

6. The Treatment
Mebendazole — known in the U.S. as Vermox — is an antiparasitic used to treat a variety of worm infestations. A hydrolase is an enzyme catalyst involved in the hydrolysis of a chemical bond. A thermophilic hydrolase is one that is active at high temperatures (such as those found in hot springs). Which seems to have no bearing on this case.

In this scene from Ultimatum #1, Sue Storm uses her force field powers to repel the tsunami of water that had flooded New York City.

It succeeds, but not only does Sue develop a psychic nosebleed, but she also falls into a coma (and the bloody nose miraculously disappears and reappears randomly over the next several panels).

Ultimatum #1 by Jeph Loeb and David Finch

Click on the image for the full scene.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine nosebleed sue storm ultimatum

In the recent episode “Bloodlines”, Chloe uses her Braniac-ish abilities to access the Kryptonian crystal in an attempt to bring Clark back from the phantom zone. Messy Kleenex is the result.

And no, I can’t explain the all-white eyes that follow the nosebleed. That’s more than I can understand, let alone attempt to explain away.

All previous Psychic Nosebleed Zen posts

Tags: comics medicine tv nosebleed smallville chloe phantom zone

It seems that whenever I visit a comic book convention, I always manage to stumble across a few public service comics I haven’t seen before. Wizard World Texas was no exception and I managed to find a few good ones. For starters, here is Supergirl (or American Honda Presents DC Comics’ Supergirl, In Cooperation with the U.S. Department of Transportation’s National Safety Belt Campaign). While not horrible, it’s not a particular good PSA — the fact that four writers are listed is always a dead giveaway. There’s about six pages of story stretched out to 28 pages. The message is somewhat muddled too, as the person who is supposed to be “learning a lesson” seems to be having a better time than everyone else.

Because she is in California dealing with an earthquake, Linda Danvers (a.k.a. Supergirl) has to cancel her date with movie aficionado Steve Gordon. Since Steve already bought the tickets, he decides to go with another girl — his younger sister. As they leave for the movie, his sister chides him to put on his seatbelt, but he declines, telling her that he “drives much better without it.” Those are dangerous words to speak when you’re in a PSA comic, and sure enough, Steve’s car is broadsided by a drunk driver. His little sister — who was wearing her seatbelt — only suffered minor injuries, but Steve took a bad blow to the head and has fallen into a coma.

Hearing the news, Linda rushes to the hospital and is dismayed when she realizes how badly Steve has been hurt. Doing what any normal person would do when she finds a loved one injured, she runs off to Superman’s Fortress of Solitude and uses some of the alien machinery there to access Steve’s mind in an attempt to bring him out of the coma.

First she finds herself in a scene that best described as a cross between the Road Warrior and the Iditarod. Steve is dreaming that he is a post-apocalyptic word and must drive his souped-up ski-car across the frozen tundra to get fuel for his town. Along the way, he needs to steer clear of the evil marauders who want to steal the fuel. Once again, he neglects to put on his seatbelt and is injured when the marauders slam a (futuristic) bulldozer into his car. In the real world, Steve’s coma worsens.

Now Steve imagines himself in an Indiana Jones scenario, but when his jeep is crushed by a Nazi truck — and he is once again not wearing his seatbelt — his medical condition takes another turn for the worse. His next dream is a classic noir setting, with Steve playing the part of a Sam Spade-like private eye. This time, he remembers to buckle his seatbelt, so is barely injured when the bald villain rams his car. Having learned his lesson, Steve wakes from his coma, none the worse for wear.

More PSAs

An above average episode of House. The medicine was better than recent episodes, though the soap opera was turned way down.

Sophia is a 16 year old emancipated minor working as a factory foreman. She sought emancipation after both of her parents were killed. While talking with a floor worker, she begins to have chest pain and shortness of breath, and then collapses, red frothy sputum flowing from her mouth.

She is admitted to the hospital for evaluation of her pulmonary edema. The initial differential diagnosis consists of parasite infection, gastrointestinal problem, pregnancy, or damage to the heart from drug use. House has Kutner perform an echocardiogram while Taub and Thirteen search Sophia’s apartment. The echo shows no structural heart disease, but the apartment search shows that she likes to build her own furniture, but it also turns up a bong. When confronted with this, Sophia claims that it is her ex’s bong, and it’s the reason that he’s an ex.

The team now considers that she may have intermittent tachycardia (occasional episodes of an abnormally fast heartbeat) due to drugs, though Kutner favors a diagnosis of vasculitis. He wants to giver Sophia steroids, but House turns him down, stating that a steroid could make an arrhythmia worse. House wants to start her on beta-blockers (a drug that lowers the heart rate) to control the suspected arrhythmia. Kutner decides to go ahead with his original plan and gives her steroids instead. A short time later, Sophia is violently yelling at the staff and having paranoid delusions. She is given Haldol (haloperidol — a potent antipsychotic) to control her outbursts. Kutner reports that labs show that her psychotic break is not due to any metabolic problem, and it was too soon to be related to the steroids.

Given the symptoms of lung problems and delirium, Foreman suggests Prinzmetal’s angina (heart pain caused by spasms of the coronary arteries) — only he suggests it involves arteries in her brain, not the heart. House thinks the idea shows promise, so has the team place her on ergonavine )a drug which can trigger blood vessel spasms) and check an fMRI (functional MRI – an MRI that looks at blood flow). Medically, this part makes little — if any — sense, but is really just used to set up the subsequent revelation. The fMRI shows no arterial spasms, but it suggests that she is lying when she talks about her dead parents. Kutner confronts Sophia and she admits that she lied about the death of her parents, and the truth is that she ran away from home because her father raped her.

The team now adds sexually transmitted disease (especially gonococcal endocarditis) and stress to her differential. House feels it is the latter and suggests that Sophia be put on diazepam (Valium) to help with the stress. As Thirteen is about to give her the medication, Foreman notes that she has reddish-brown urine which wouldn’t be caused by stress. A microscopic examination of the urine reveals “shredded red blood cells.” E.coli, Shigella, and Legionnaires Disease are all suspected, but House believes her symptoms are caused by arsenic poisoning from building furniture with treated lumber. The tests apparently support this and she is started on chelation therapy for the arsenic. After the therapy, when Sophia is ready to be discharged (which is always dangerous in House’s world), she suffers a seizure. A repeat MRI shows brain lesions that were not there just a few days before. Infection (syphilis in particular) and cancer are suggested, but shot down. Then Thirteen suggests acute promyelocytic leukemia (APL). A brain biopsy confirms the diagnosis. Arsenic is used to treat APL, so removing it from her system allowed the leukemia to spread. Giving her more arsenic may slow down the cancer, but according to House, bone marrow transplant is needed for the cure. A family donor would be best, but Sophia refuses to let them tell her parents. Disregarding her wishes, Thirteen visits Sophia’s family only to discover that Sophia has been lying and using a stolen identity. Told of this, House believes her responses are too rational and confronts her. She admits that she ran away from home because she killed her younger brother. House convinces her to contact her parents, and in the end we witness a tearful family reunion.

Meanwhile, Foreman is treating his own patient: Jonah, a four year old boy with several days of unexplained lethargy, diarrhea, and bloody vomiting. The standard tests are all normal, so Foreman proceeds with a capsule endoscopy (a swallowed wireless camera to transmit pictures of the inside of the gastrointestinal tract). As he swallows the camera, Jonah starts giggling uncontrollably with no provocation.

Foreman asks Cameron and Chase for help, and they consider meningitis, thyroid, stomach cancer, and porphyria, but all tests are negative. As they are wondering whether they should involve House, Jonah has a cardiac arrest, but is successfully revived.

Foreman does finally go to House and ask for help, but House turns him down. Commiserating with Cameron and Chase he has his own Eureka! moment when he realizes that Jonah is suffering from iron toxicity from all the extra vitamins his brother had been feeding him to make him stronger.

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

Once again, you do not shock a flatline.

I mentioned this above, but “Prinzmetal in the brain” to be diagnosed with ergonovine and fMRI is nonsense — and dangerous if it worked. If it did cause a spasm, then they just caused a stroke (or at least a TIA) in sixteen year old. How were they planning on correcting that?

fMRI has been studied as a lie-detector – Mythbusters featured it in one of their episodes. It doesn’t work quite as neatly as it did on the show. For one thing, small movements — like talking — will throw it off. Also, while the limbic region of the brain may house “imagination,” it is also important in emotions and long term memories — so it lighting up while talking about dead parents would be expected.

From my reading on APL, it is treated primarily with specialized chemotherapy (including arsenic trioxide) and has a very good response rate. Bone marrow transplant is not considered unless there is a recurrence.

Valium is overkill for an anxiety disorder. That class of drug (benzodiazepines) is not a bad choice for acute anxiety, but there are better choices than Valium, particularly in a sixteen year old.

I don’t know what procedure Wilson was going to perform, but it’s best to put on your surgical mask and eyewear before scrubbing.

Interesting how they immediately ruled out cancer as a cause of the brain lesions…and then ended up diagnosing APL, a type of cancer.

Neither medical mystery featured dramatic symptoms, but both were solid puzzles and earn a B+. The solutions were both logical and fit fairly well so deserve an A-. The medicine was better than the past several episodes but still had some large holes. Foreman’s case was handled better, but he was still stumbling around more than he should. Still, it was better than average (especially this season), so earns a strong B-. The soap opera aspects were minimal, though it was nice to see House interacting directly with the patient. I give this aspect another B-.

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

Chris has this week’s high score with 12 points. To round out the top three, Louwrens gained 9 points, and Joanie gained 7 points.

Overall, Sable Hope remains in first with 30 points. JockM is second with 28 and Ash is third with 27. Chris jumps up to fourth with 24. and The Erskine holds relatively steady in fifth with 20 points.

Full scores are available here.

A surprisingly watchable episode of Fringe, probably the best yet. There were enough strange coincidences and evil psychiatrists to (almost) make me forget the whole nonsense of “The Pattern.”

The Story: Ben Stockton, a ten year old musical prodigy, is kidnapped by a mysterious woman after his father is put in a trance by red and green flashing lights. After Agent Dunham picks up the case, Broyles tells her that there have been four previous kidnappings, all experts in one field or another, all by the same mysterious woman, and all four of the victims ended up insane. Dr. Bishop recalls hearing of the red and green lights before, and eventually remembers that it was from another inmate at the asylum where he used to reside. It seems there was a fifth kidnapping that even the FBI was unaware of, and the victim ended up admitted to an asylum for the criminally insane. Walter recalls that the patient was fixated with an equation he couldn’t solve. Peter realizes that when that equation is expressed in musical notation, it is the same mysterious composition Ben had recently become obsessed with.

Agent Dunham figures the best approach is to interview the patient, but the director of the asylum won’t let the patient be interviewed by anyone except Walter Bishop. Reluctantly, Walter agrees to return to the asylum to conduct the interview, but while there he is sedated and held by the guards and director, who then informs Agent Dunham and Peter Bishop that he is retaining custody of Walter for his own safety. The next day, Dunham is able to procure a court order to release Walter, but it is clear the asylum director is up to something. Walter was unable to get much from the other patient except for some mumblings about a red castle. This is enough for Dunham to locate the villain’s lair and rescue Ben, but the mysterious woman is able to escape (though she ultimately meets her demise at the hands of a turncoat accomplice).

1. Nothing To See Here
The hypnotism scenes are pure science fiction, but I have no significant medical or scientific complaints other than that. A first for the show.
Does the red/green flashing cause a hypnogagic trance, or make the patient susceptible to suggestion? The show suggested both.
Agent Dunham should have stormed the castle with a team of red/green color blind agents. That would have caught Ostler unprepared.

2. Music
Walter Bishop transcribed the equation into “9 bars” of music, but it sure seemed like Peter played for longer than that.

3. Psychiatrists
This episode is another good example of Scott’s Third Law of Comic Book Physicians — when a character is introduced as “psychiatrist”, it is shorthand for “they are up to no good.”

Nightwing #148 “The Great Leap, part 2″
Peter J. Tomasi, writer
Rags Morales, penciler

After being shot with a bullet in the right shoulder, Nightwing makes it to the Batcave where Alfred performs arthroscopic surgery to remove the bullet fragments.

Arthroscopic Surgery (also called arthroscopy) is a type of joint surgery which uses a special fiberoptic scope that allows the surgeon to explore and repair the injured joint while minimizing the trauma from the surgery itself. The scope is attached to a camera and the surgeon follows the action on a video screen. Arthroscopy can be used on a variety of joints (shoulder, knee, spine, etc.) and for a variety of procedures — in this case, removal of a foreign body.

A small incision is made for the arthroscope and another small incision is made for any additional instruments (a blunt probe is commonly used; A pair of forceps to remove the bullet is used here). The surgeon watches the video screen as he manipulates the arthroscope and other instruments. The joint is explored, bullet fragments are found and then removed. The instruments are then withdrawn and dressings applied to the incisions. Healing time is quicker than traditional open shoulder surgery — athletes can usually return to action within a few weeks to a month. On the other hand, I think it’s fair to say that Nightwing running off an hour or two later to resume the good fight is not one of his better ideas. He must not be particularly fond of using that shoulder.

Depending on the location and extent of the surgery, general, epidural, or local anesthesia can be used. Alfred is grousing because Nightwing asked only to use lidocaine — a local anesthetic — for the surgery. Given the wound location, this is actually a reasonable choice. The lidocaine could be used as a local anesthetic or to provide a brachial plexus block (the brachial plexus is a collection of nerves in the shoulder that contains all the nerves of the arm). The latter would be the best option, but as it affects the entire arm and takes several hours to wear off, it would limit Nightwing’s ability to go gallivanting across the rooftops later that night.

Other thoughts:
Nightwing tells Alfred to avoid nicking a nerve, which is an unusual request as there are no nerves in the shoulder joint. He might be referring to the incision into the shoulder, but at the time he says it, Alfred’s already well into the operation.

The arthroscope doesn’t provide any advantage in removing the bullet from the wound in Nightwing’s side. It’s not a bullet lost in a wide-open joint, but instead one lodged in the abdominal muscles. A standard surgical exploration would be best.

I see that Alfred is not wearing eye protection or wearing a full surgical gown. Given that he considers Nightwing “family,” he might feel that these aren’t necessary. Anyway, I doubt OSHA is likely to spring an inspection on the Batcave.

I suspect Alfred reads the journal Arthoscopy. From the June 2007 issue of the journal, in the abstract of an article entitled Acute Arthroscopic Removal of a Bullet from the Shoulder:

“Bullets and lead particles in synovial fluid dissolve in time and cause periarticular fibrosis, chondrolysis, hypertrophic arthropathy, and sometimes chronic lead intoxication.”

Here’s what our favorite surgeon/butler tells Nightwing:

“…otherwise the lead particles in the synovial fluid could dissolve in time and cause periarticular fibrosis, chondolysis, even hypertrophic arthropathy.”

As usual, Rags Morales provides solid medical-related art. However, if I, if I really wanted to nick-pit, I would point out that arthoscopic images are always round (because the camera looks through the round scope — and speaking of cameras, there doesn’t seem to be one attached to the scope. It should fit over the eyepiece).

One last thought: Alfred’s priorities and sense of timing are horrible. Nightwing showed up to the Batcave bleeding from a bullet wound. Alfred’s first priority was to stop the bleeding. After accomplishing that, there was little need for him to perform joint surgery and remove the bullets at that time. The complications he describes are all chronic conditions and would take weeks, if not months, to occur. If he knew Nightwing was going to finish his mission as soon as possible (and you know he did), then Alfred should have postponed the surgery until later and spare Nightwing any surgical complications and need for recovery while fighting crime that night.

I know that making fun of Wizard is like kicking someone when they’re down, but this has got to be one of their stupidest articles ever:

I doubt the person who wrote this has ever seen an episode of Fringe, let alone read an issue of the Fantastic Four. It hurts my brain to read this.

Scanned from Wizard #206

The Drummer is thrown for a loop when he he caught in a dimensional shift along with the rest of the Planetary team. Unfortunately for him, when you’re tied into the electrical/information system of the entire planet, the change can be quite jarring.

Planetary/Batman: Night on Earth by Warren Ellis and John Cassaday

All previous Psychic Nosebleed Zen posts

Tags: comics medicine tv nosebleed planetary drummer

Seventh grade science class was the first time I got to play with microscopes. They were your old beat-up standard issue school microscopes with three lenses (but you could never use the highest power one because it was an oil immersion lens and what school could afford the oil?). We used the microscopes to view a variety of microscopic creatures such as volvox and paramecium. That was all fine and dandy, but I wanted something more — I wanted to see blood. Luckily, I had just had two teeth pulled (thank you, orthodontist), and figured I could get some blood from one of the sockets. Our teacher said I could give it a try, so I took a drop of blood, placed it on a microscope slide, put a cover slip on, slid it under a microscope, took a look — and I saw nothing. No cells, no platelets, nothing. I learned the hard way that looking at blood under a microscope simply isn’t that easy.

The slide needs to be specially prepared first. A blood smear is the easiest way to do this. A smear spreads out the blood in a very thin — nearly two-dimensional layer — so that each individual cell can be seen. Without the smear, there is just a thick pool of blood cells stacked on top of one another that’s all but impossible to interpret.

Once the blood smear is dry, it can be viewed under the microscope. This will give the basic idea of what’s going on, and most cells can be seen, but for a better view — the one we’re used to seeing in movies and television shows — the blood smear needs to be stained. This allows the various blood cells to stand out. Unfortunately, it’s also a labor intensive and time consuming process.

Why do I bring this up? Because of scenes like this, that routinely pop up in comics*:

If only it were that easy. I would’ve been a very happy seventh grader.

*And it’s not just comic books, it shows up in television shows and B-movies all the time as well. This issue of Ultimate Spider-Man (#125, Bendis and Immonen) was just the most recent example I ran across.

A low scoring week. Lots of players guessed a variety of zoonoses and tropical diseases, but only one got the final answer right.

yarnpiggy has this week’s high score with 12 points. Teatime is second for the week with 4 points and there were a handful of players with 3 points.

Overall, Sable Hope and Ash are in first with 30 points. JockM is third with 28 points. Chris and The Erskine are in fourth with 24 points each.

Full scores are available here (including corrected scores from last week).

A cleverly set-up episode of House with some unfortunately very sloppy medicine.

House is rooting around in Cuddy’s desk when Jason, a patient, enters looking for Cuddy. House shoos him away, but a few minutes later he returns, armed with a pistol and dragging along a handful of clinic patients and staff he has taken hostage. He tells House that he’s sick and he wants the best doctor in the hospital or he will start killing patients. He explains that he has seen 16 doctors in past 2 years, had 3 CTs, 2 MRIs and 7 blood panels, but no one can figure out what his wrong with him. His symptoms consist of shortness of breath, fatigue, rashes, palpitations, and insomnia. House takes the case. He focuses on the lungs first and has Jason try, unsuccessfully, to blow out a lighter. From that, House deduces that he has low lung volume and tells him that he has pulmonary scleroderma. He recommends treatment with Propofol.

Now, scleroderma is a real disease and can certainly cause pulmonary symptoms, but it doesn’t generally cause the symptoms this patient is exhibiting. Nor is it treated with an “alkylating agent.” So is House trying to be clever and use an impressive sounding disease name to fool the patient, or is it sloppy writing? I like to think it is the former. Regardless, House was trying to be clever by using Propofol, which is not a treatment for scleroderma but instead a powerful intravenous anesthetic. Unfortunately, when Jason had him give it to a hostage first, House’s deception was revealed when that hostage collapsed. In retaliation, Jason shoots another hostage in the leg.

The SWAT team arrives on the scene as House has a conference call with all his young guns. Chase refuses to play along and leaves. The rest of the team comes up with a differential diagnosis of chronic lung infection, cancer which has spread to the lungs, a neurological condition affecting the diaphragm, or a heart defect. As House is ordering a variety of tests over the phone, Jason hears some SWAT personnel outside the office window. House is impressed because no one else in the room heard the police officers. He decides that Jason has hyperacusis (an extreme sensitivity to sounds) and this seems to point to a neurological cause. A slight left facial palsy (weakness of the muscles on the left side of the face) is also noted, and House now suspects that Jason has postherpetic neuralgia (chronic pain following a shingles outbreak). He orders some Capsaicin (the chemical that causes hot peppers to be hot) to test the nerve. This is an acutely painful test, but Jason makes Thirteen go through it first. She doubles over in pain. Jason is next, and he suffers the same amount of pain, ruling out postherpetic neuralgia. Meanwhile, the white blood count has come back normal, meaning that infection is not the cause (or at least less likely to be the cause), so that leaves a heart defect or cancer as the cause.

About this time, Thirteen notices that Jason has a distended jugular vein. His pulse is also racing along at 160 (a normal pulse should be no higher than 100). House tries carotid massage to bring the heart rate down but it doesn’t work. House doesn’t want to defibrillate Jason as the electrical shock could cause him to tighten his trigger finger and shoot someone. Instead, Thirteen suggests a chemical cardioversion (using medicine to return the heart rate and rhythm to normal). This is risky because it they don’t know for sure what the exact heart rhythm is. Regardless, House agrees to give it a try. She rushes out to the clinic and grabs some adenosine. Jason makes her take it first, and she blacks out from the low heart rate it causes. It works well for him though, returning his heart rate to normal.

Now House notices that Jason is just sweating on one side of his face. This makes him think that Jason has a Pancoast tumor, a lung cancer high in the lung pressing against some key nerves. Jason confirms that he has dry mouth and House finds a swollen lymph node in his neck, all of which seem to confirm the tumor theory. Jason trades two hostages for access to the CT scanner. The initial CT scan is inconclusive because the metal in the gun interfered with the scan. House talks him into giving up the gun and repeats the scan — it is normal. There is no tumor and House is stumped. To the dismay of Thirteen and the one remaining hostage, House returns the gun to Jason.

House talks to his team again, this time looking at the symptoms of dyspnea (difficult breathing), anemia, seventh nerve palsy, and tachycardia. Loa loa filariasis (an African parasite), Q fever (a bacterial infection caught from cattle or similar animals), histiocytosis X (an older name for langerhans cell histiocytosis), and Cushing’s Disease are all suggested. The latter seems the most likely, so House orders some Dexamethasone (a potent steroid) to test for the condition. Once again, Thirteen is forced to take the drug first. The patient is given the medication next, but it makes no difference in his breathing, so Cushing’s is ruled out. Unfortunately, all the medications have caused Thirteen to develop acute kidney failure and she becomes very sick. The team is puzzled that Jason didn’t have the same problem, and decides that he must have something protecting his kidneys. House finds Chvostek’s sign, which an indication of low calcium. Looking through his charts, the team decides that this is due to the proton pump inhibitor (PPI) he is taking (PPIs are stomach medications such as Prilosec, Prevacid, etc. By lowering the acidity of the stomach, they decrease calcium absorption and can lead to low calcium). The team decides the low calcium must be protecting his kidneys and whatever disease he has must have a long incubation (the leap of logic here seems a little abrupt). Leishmaniasis and melioidosis are suggested, but dismissed because they are tropical diseases. When the patient admits that he’s been to Florida, House tells him that’s tropical enough and melioidosis is the likely culprit. He orders 3 grams of ceftazidime (a potent antibiotic and the preferred treatment for melioidosis), but is forced to leave the room. Only Thirteen and Jason remain. She begs not to have to take the drug as she doesn’t want to die. Jason relents and takes the injection just as the SWAT storm the room. As he is led away in handcuffs, he indicates to House that he is already breathing better.

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

Post herpetic neuralgia affects one particular nerve on one side of the body. If Jason has problems with his left facial nerve, giving him an injection in his back/buttocks will do nothing or prove nothing as it is nowhere near the only affected nerve.
Postherpetic neuralgia is a painful condition that sometimes has numbness associated with it. This does not match the patient’s symptoms at all.
Topical capsaicin is used to treat postherpetic neuralgia, and there has been a study of an injectable form for other causes of neurological pain, but I can find no record of it being used to test for postherpetic neuralgia.

I’m not sure what the writers were trying to show with the dexamethasone. It can be given in low doses over several days to diagnose Cushing’s Disease or Syndrome. A higher dose can be given to differentiate the causes of the condition, but it’s not used to treat Cushing’s. Remember, in Cushing’s, the patient has too much steroid in their system, so giving them more (like Dexamethasone) doesn’t correct their symptoms (why would it?), but it may temporarily cause the body to slow down the amount it makes — but this takes several hours, or days, to have an effect. It is a lab test; it has nothing to do with symptoms.

Hyperacusis means that patient has an increased sensitivity to everyday sounds. It does not mean that their hearing is any better.

The time course of this episode was extremely off. Medications simply do not work that fast. The writers had the dexamethasone working too fast (takes a day or two), the ceftazidime kicking in too fast (a few weeks not a few minutes), and Thirteen’s kidney failure hit within minutes.

Adenosine is an extremely short acting drug that only lasts a few seconds. It would have been out of Thirteen’s system quickly. While it can cause a brief heart block, it doesn’t cause people with normal hearts to collapse like that.

Previously unmentioned symptoms kept appearing for no reason. First, House mentioned that the patient had “abdominal pain,” though Jason had never mentioned it. Later on, “anemia” showed up as well though it had not been mentioned previously.

If a tumor were large enough to cause all those symptoms, you would think that it would show up on at least one of the CT scans in the pat two years.

There has not been a case of melioidosis in the US in over sixty years.
Ceftazidime is the drug of choice, but the maxiumum dose is 2 grams per dose, not 3.

You don’t give a high dose antibiotic shot in the cubital fossa. It needs to go in a big muscle, or an IV line.

There are much better method’s, though none so dramatic, of inducing Chvostek’s sign. I don’t think House’s technique would even work.

Propofol is an intravenous drug, not intramuscular.

Don’t talk during the CT.

The medical mystery was interesting, and the setting clever, so the show started out with a strong A-. The final solution was quite a stretch (for instance, it just happened to be the last tropical disease mentioned, rather than the two previously discussed) and earns a C. The medicine, even given the conditions, was sloppy and deserves a D at best. The soap opera was well done and almost made me sympathetic to Thirteen; I give it a B+.

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

A clever initial premise spoiled by Dunham’s botching of the investigation. The medicine/science was hit or miss.

The Story: Mark Young has just finished delivering a successful presentation at Massive Dynamic and is relaxing in the conference room. He sees a butterfly, but when he tries to get a closer look, it cuts him with its razor-sharp wings. He smashes it, but another appears, and another, and then an entire swarm, all slicing his skin with their wings. Trying to escape from the swarm, Young runs wildly and breaks through the window of the conference room, plunging to his death on the street far below.

Agent Dunham and her team are called in to exam the body. Dr. Bishop notes compound fractures and internal bleeding – consistent with the fall — but also many deep cuts, with many of them under Young’s clothes, so broken glass couldn’t have caused them. Bishop has Young’s body shipped back to his lab for an autopsy, and that’s when he notices that the cuts all seemed to be made from the inside out.

Agent Dunham receives a mysterious e-mail from the late Agent Scott, her former partner and lover. It directs her to a basement room in an abandoned building filled with boxes of toads. Bishop recognizes the toads Bufo alvarius, which are known for secreting a hallucinogen. He identifies a concentrated form of this toxin in Young’s body and deduces that he essentially died of fright (well, that and a thirty-story fall) and the cuts were all psychophysiological (i.e. psychosomatic — caused by his own mind).

Dunham decides she needs to access Agent Scott’s memories since he seems to have had a connection to Young. She goes back into the sensory deprivation tank from the first episode and discovers a memory of Scott meeting with Young and two other people. It seems that Young was selling secrets from Massive Dynamic. Young goes off with one man while Scott stabs the other. Agent Dunham is now determined to track down this remaining fourth man. Using some not-so-subtle clues from Young’s date book, she discovers he is George Morales, an infamous smuggler. The team goes on one of their SWAT-lite raids and successfully apprehends Morales. He offers tell Dunham everything he knows in return for protection from Massive Dynamic. He claims that they are behind “The Pattern” and are using it as a cover for their illegal activities. Dunham goes to confront Nina at Massive Dynamic, but while she is there, Morales dies mysteriously, his throat cutting itself open — apparently he was given the same drug as Young and imagined Agent Scott cutting his throat.

1. Psychosomaticism
Assuming that I accepted a psychosomatic cause for Young’s cuts (and I don’t — there’s simply no process by which it could work), why would the cuts be from the inside out? It makes no sense. If he were mentally replicating the wounds he was imagining, they would be external, not the other way around.

2. Toad Lickers
The toad Bufo alvarius is found in the southwestern United States. It secretes two hallucinogenic drugs, bufotenin and 5-MeO-DMT, that are effective if inhaled, injected, or ingested. Bufotenin is the more potent of the two. Reports from users indicate it is not a particularly pleasant drug. In terms of fear, high doses have been known to cause extreme anxiety and a sense of impending death. Of course, the higher doses also tend to turn the face of the user a dusky purple color from vascular congestion.

3. Why?
Unrelated, except that the ad was shown during the show. Why in the world are they remaking The Day the Earth Stood Still, one of the true classics of science fiction cinema — and with Keanu Reeves, no less?

4. Micromanaging
All the strange equipment and requisitions for Bishop’s lab, and the only thing her supervisors ever questions is an aquarium and food for toads? What about the cow? The grand piano?

5. Can’t Find Her Way Out of a Paper Bag
I’m losing more respect for Dunham’s supposed keen investigative skills every episode. The clues and answers are all spoon-fed to her. And then, when she finally is on the verge of learning something truly important, she abandons her source and runs over and accuses Massive Dynamic before actually getting the evidence. So not only is the source killed before actually divulging the important information, but she telegraphed everything to Massive Dynamic. Great job, Olivia.

Dennis the Menace #56 (1962)

Happy Thanksgiving!

To qualify for this list you need to be female sword-slinger whose adventures have appeared primarily as short stories, novellas, and novels. In addition, I’m looking for characters with staying power: there are a number of good female characters who have appeared in a single story, but I want to focus on those who have appeared in a number of books or stories.

My top three are pretty much written in stone. They may not be everyone’s top three, but they better be in everyone’s list of five. If not, well, you’re wrong and you should come back after you’ve thought things over and admitted your mistake.

Numbers four and five are certainly open for debate, though.

Honorary mentions:
Jame (P.C. Hodgell), Kerowyn (Mercedes Lackey), and I’m sure there’s a swordwoman somewhere among Bradley’s Darkover novels.

I was pretty sure I knew what was going on in Narcopolis — at least for the first three issues — but the farther I read in the last issue, the more I felt that understanding slipping away. When I finished the story, I was pretty sure Delano really didn’t know what was going on either.

Regardless, here’s a nice psychic nosebleed from the climax (so to speak) of the story.

Jamie Delano’s Narcopolis #4 by Jamie Delano and Jeremy Rock

All previous Psychic Nosebleed Zen posts

Tags: comics medicine tv nosebleed narcopolis jamie delano