Polite Dissent

Sue Storm (well, Ultimate Sue Storm) is using her forcefield powers to protect her and her friends from harm — with mixed success — while fighting one of the nameless antagonists from Ultimate Enemy #3.

All previous Psychic and Superpowered Nosebleed Zen posts

Tags: comics medicine nosebleed sue storm ultimate

This episode of House started off strong, with an interesting mystery, and kept the moment — for the first half, anyway. Then it settled into its all-too-common mishmash of acronyms and quasi-medical reasoning.

Ted is a twenty-seven year old about to get married. As he stands at the altar, he suddenly finds that he is unable to speak, and then he collapses. He is admitted to the Emergency Department, where House’s team evaluates him for his “aphasia” and “syncope.” He is told that the initial work-up has excluded infection, vocal cord damage, stroke, low blood pressure, low blood sugar (hypoglycemia), and dehydration. House clearly suspects Ted got a case of cold feet about the wedding and is faking his symptoms. Surreptitiously, he stabs Ted with a needle causing him to scream out loud. Ted seems amazed that he is now able to talk. This sudden resolution of his symptoms lends credence to House’s suspicions and Ted is discharged from the hospital.

Of course, this is House, and being discharged is a sure sign that worse things are about to happen, and — sure enough — once outside the ER, Ted suddenly starts coughing and then gasping for air. Once again, he collapses. A chest x-ray reveals a substantial pleural effusion (extra fluid building up around the lung). House is reminded that the ER found no evidence of infection and Chase insists that there are no parasites (the eosinophils, a type of white blood cells which are usually elevated in parasitic infections, are normal), but House wants to make sure. He orders the pleural fluid cultured, and run through cytology (looking for infection and cancer). He has half the team search the house Ted shares with his fiancée, and the other half check the apartment he used to live in. Apparently, the search of his current home showed nothing because it was never mentioned again. The search of the old apartment turned up some interesting things: possible lead poisoning, possible asbestos exposure, and an old ex-boyfriend.

The lab tests on the pleural effusion show that it is the result of a mono (mononucleosis) infection. This is an unusual presentation for mono, so the team wonders if Ted may be immunosuppressed — in particularly, if he has HIV (the virus which causes AIDS). The subsequent test is negative. When questioned, Ted tells Thirteen that he was gay once, but was “cured” by attending intensive conversion therapy which included aversion therapy (looking at gay porn while receiving emetics, i.e. drugs that cause vomiting), male hormone injections, and ultimately, electroconvulsive therapy (ECT, i.e. “shock therapy”). The team wonders if the ECT may have caused some brain damage, so an EEG is ordered. It is normal, but then Ted suddenly suffers a cardiac arrest; luckily he is resuscitated with the help of a handy defibrillator. The team now evaluates why Ted suffered the cardiac arrest (which they keep calling, incorrectly, a heart attack). His EKG is normal, as is an electrophysiology study (a look at the electrical pathways within the heart). They decide to proceed with a cardiac catheterization (evaluating the arteries which supply the heart with blood). While they are describing the procedure to him, he suddenly faints. They sit him up, and he faints again. This leads House to diagnose him with POTS (postural orthopedic tachycardia syndrome). According to the team, this diagnosis explains virtually all of his symptoms. It can be caused by infections such as mono, which is probably how he developed it. He is started on fludrocortisone for treatment (fludrocortisone increases sodium retention leading to improved blood pressure and blood volume).

A short time later, Ted starts complaining of a severe headache. Infection is considered a likely cause, so a spinal tap is ordered. This offers no answers and only seems to make the headache worse. House now suspects that Ted has a CSF (cerebrospinal fluid) leak where the spinal tap was performed, leading to low CSF and a spinal headache. He has the team apply a blood patch to stop the leak. About this time, Ted develops left-sided facial drooping. The rest of his neurological exam is normal (except for the headache). An MRI is obtained, but is normal. Various diagnoses are considered including sarcoidosis, scleroderma, histoplasmosis, and MELAS (Mitochondrial myopathy, Encephalopathy, Lactic Acidosis, and Stroke syndrome — a genetic neurologically degenerative disease), but none seem to fit. House decides to have the team get a good history from Ted, but this time with both his fiancée and ex-boyfriend present. With prompting, it turns out that Ted had a fainting spell at least once before, and he has had some erectile dysfunction (trouble getting an erection) with his fiancée. The team wonders if there may be an underlying vascular problem causing his symptoms, including his erectile difficulties. A penile plethsmyograph is ordered, but is normal. However, Thirteen notices that Ted is now suffering from galactorrhea — in other words, he’s lactating. Thyroid diseases, including Graves and Hashimotos, are considered but then discarded. Taub suggests a pituitary tumor. It makes a certain amount of sense, so a pituitary MRI is ordered and a prolactin level is checked. Once again, everything is normal (were there any abnormal tests or radiology in this episode at all?) Meanwhile, House is having a conversation with Wilson that leads to his Aha! moment of the week: Ted has a Chiari malformation. This is a narrowing of the skull which puts pressure on the cerebellum, cutting off normal CSF flow. Ted had not previously had any symptoms, but the slight swelling of the brain caused by the electroconvulsive therapy was enough for the malformation to cause his symptoms. Some surgery and Ted’s symptoms resolve.

For the first half of the show, I was thinking that the mystery was really engaging and the medicine was better than usual. Then he had his “heart attack” and things went downhill from there. As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

A cardiac arrest and a heart attack are not the same thing. A cardiac arrest occurs when the heart stops beating (arrests) — this can be due to heart attack, or to a number of other cardiac condition such as arrhythmias. A heart attack occurs when the heart is unable to get the oxygen it requires and part of it infarcts (dies).
Why did Ted suffer the cardiac arrest? Was it supposedly the pressure on the brain from the Chiari malformation? Really?

How did the Chiari malformation cause Ted’s aphasia? Was it the vague “increased pressure?” Amazing how his condition only caused each severe symptoms (aphasia, cardiac arrest) once.

I have no idea if ECT can cause a generalized brain swelling, but one that persists after three months? That is definitely wrong and worrisome.

The time frame seemed a little suspicious to me. Not impossible, just unlikely. Ted received his hormones/ECT and moved out of his old apartment just three months before the wedding. So was that an incredibly quick engagement, or was he dating Nicole while he was still “gay.”
And the most unlikely part: reserving a church for a wedding three months away.

Nice HIPAA violation Thirteen, telling a (for all you know) complete stranger that Ted has been hospitalized.

House’s treating Ted’s headache with a blood patch did nothing to correct Ted original headache, it only cured the secondary headache that the team caused.

Penile plethsmyograph? Not standard of care. And giving him a medication to cause an erection defeats the purpose of the test, since the medications usually work on even vascularly compromised individuals.

It was a good medical mystery tonight: what caused the aphasia and collapse. I give it a B+. The final solution was a stretch. It covered some symptoms well, but for the others you had to squint your eyes just right and hope the stars were in alignment: C. The medicine started off good and for the most part, proceeded logically. They were to quick to grab onto POTS and too slow to let it go, and the cardiac arrest/heart attack confusion was a major mistake: C-. The soap opera was very good, House played well off of everyone tonight: solid A (and for the record, I grade the soap opera because it is an important part of the show; I don’t go into detail about it because these posts are already long enough).

The review of the previous episode of House
A list of all prior House reviews

Once again, Buzzy is starring in a public service ad, and as is common (at least for his PSA appearances), he’s sticking his nose into other people’s business. This time it’s Jeff, who seems to be getting a little over excited. Luckily, Buzzy is there to set him straight and convince him to talk to the school counselor who miraculously solves his problems in a single visit. Way to go, Buzzy! Way to go, Mr. Adams.

Click on the image for the full ad

This PSA appeared in DC comics from May 1951. The script is by Jack Schiff with art by Win Mortimer.

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Back in her third appearance ever, Wonder Woman fought Dr. Poison, the Chief of the Poison Division for Nazi Germany. The doctor’s plan? To pour the drug Reverso into the water supply at the local Army base. As the name suggests, the drug causes all who are under its influence to act the exact opposite of how they were commanded. This would turn Army training into chaos, rendering the U.S. military powerless, and eroding the nation’s morale.

Of course, it’s the Bizarro style of “opposite” we’ve come to expect from comic books (though this story predates Bizarro by a good 16 years).

In the end, Wonder Woman triumphs (no surprise there) and manages to reverse the Reverso. Dr. Poison is captured, but managed to make a few more appearances during the ’40s before being forgotten. An interesting change of pace is the Dr. Poison was actually a woman disguised as a man, making her one of the first female super-villains who wasn’t just a femme fatale. A new Dr. Poison, the granddaughter of the original, showed up about ten years ago in the Wonder Woman comic and has been seen sporadically since.

According to the new Dr. Poison, the original Dr. Poison’s death can be blamed on Reverso. In creating the drug, the good doctor somehow reversed her aging process and grew too young to remember to take the antidote.

Tags: comics medicine wonder woman reverso drug dr poison

This episode of Fringe started out great, but crashed and burned in the last twenty minutes. Stupid adrenalin trick.

The Plot: Peter Bishop is heading west and stops by a diner in a small town in (nonexistent) Noyo County, Washington. He flirts with one of the waitresses who promises to make him a music mix CD and drop it by his hotel. He waits in the lobby, but she never shows. The next morning he discovers the waitress has disappeared and the police want to question him as a suspect. Luckily, he has a good alibi and a glib tongue. The waitress’ dead body is found a short time later, missing part of her skull and a piece of her brain. This makes Peter suspicious that Newton is involved, especially since he thought he spotted him in the crowd around the diner.

Peter explains to the local police that he a consultant for the FBI and offers to help them on the case. He tells them about Newton, and explains his suspicion that Newton is hunting him. Peter decides to turn the tables and use this as a chance to finally capture Newton. An autopsy of the waitress shows a high level of adrenaline, but nothing else of interest, so Peter retires to his hotel. The phone rings, but only static and muffled voices can be heard. The phone rings a second time and it’s the Sheriff telling him that her deputy Ferguson has disappeared. Peter joins her in the search, but they find nothing of importance. Peter hears a strange sound from the nearby woods and rushes in to find Newton and another man. A gunfight follows, but Peter loses track of them in the forest. When the Sheriff catches up with Peter, she tells him that she saw no other people and all but accuses him of hallucinating.

About this time, another body with part of the skull missing is found. Fearing it might be Deputy Ferguson, the Sheriff and Peter arrive to discover that it is another local girl, again with part of her skull missing. No connection can be found between this victim and Peter, making him wonder how much of this might be his imagination. With a jump of Walter-like logic, Peter deduces that he can use the adrenalin levels in the corpses to help him locate the hunter. The levels will help him pinpoint how far away from their abduction sites were the victims killed. He is able to identify several square miles of interest. The Sheriff points at an old dairy farm in the zone as the most likely location for the killers. She and Peter drive up there and meet the caretaker, who tells them nobody’s been at the farm for years. He shows them a map of the dairy farm, and it’s quite extensive. While the Sheriff goes to call for more help in the search, Peter stumbles across the mix CD the waitress made him, proving that the caretaker was involved in the murders. The caretaker lunges at Peter, but Peter is easily able to batter him senseless. In the end, it turns out that the caretaker was the lone murderer who had become fixated on the girls. The missing pieces of brain? A killer’s quirk (and a convenient red herring). He also tells them where to find Deputy Ferguson, who is wounded but still alive.

The killer caught, Peter lies down in his hotel room, ready to get his first good night’s sleep in days when Newton suddenly shows up in his room. He introduces his companion, “Mr. Secretary,” who, as we suspected, is the Walter from the alternate universe and Peter’s real father.

1. Sypathetic
Let’s look at Peter’s adrenalin idea, and look at the many reasons it wouldn’t work:
The idea: There is a bunch of extra adrenalin in the muscles of the victim, and Peter believes that there are two spikes of adrenalin, one from when they were abducted, and a second from when they were actually killed. By knowing the speed at which adrenalin is “absorbed” he figures he can deduce the time between the two spikes and thus the distance between the two events.
Let’s look at just a few of the major problems with Peter’s plan:
1. Adrenalin is adrenalin, how is he going to differentiate the adrenalin produced during the first spike from the adrenalin produced during the second spike.
2. It’s a moot point anyway, adrenalin has a very short half-life and the adrenalin from the abduction would be long gone by the time they were killed (and the adrenalin from the murder itself is probably long gone too).
3. You can’t base a control level on a single person, especially when that person is trained sufficiently to have a better fight-or-flight response than the average person, and, more importantly, the control person is alive while the others are dead (i.e. active metabolism versus no metabolism)
4. Peter’s making a helluvalot of unwarranted assumptions:
There were only two adrenalin spikes.
The killer drove exactly 45mph — and drove in a straight line.
The victims were murdered the minute the killer arrived at his hideout
The bodies were found exactly the same length of time after death
Everyone, regardless of weight, muscle mass, and metabolism, “absorbs” adrenalin at the same — and constant — rate

2. They Always Said Wonder Bread Is No Good For You
Potassium Bromide is a known (or at least strongly suspected) carcinogen. It was used to improve flour, and is still used by some US bakeries. It has been linked to peritoneal mesothelioma.

3. Glimmer, Glimmer, Glumpkin
Walter may not want to use his glimmer detector to find Peter, but certainly it would work to find Newton…

I was liking the Peter-centric aspect of the episode and the mystery was intriguing, but then the even-CSI-wouldn’t-touch-it-with-a-10-foot-pole adrenalin scene occurred, followed by the let down of a solution with too many convenient red herrings. The blatant product placement just added insult to injury. I dock the clock a minute for what started out as a winning episode.

Tags: television fringe murder adrenalin glimmer

Maxwell Lord is back, and he’s here with one of the biggest psychic nosebleeds ever. Really, what more can I say (except that I’m glad I’m not cleaning up the mess)?

All previous Psychic and Superpowered Nosebleed Zen posts

Tags: comics medicine nosebleed maxwell lord blood

Though the medicine was sloppy and at time contradictory, I liked this episode of House. The way it was staged was clever, and it was nice to see Alvie again — though a little goes a long way as far as he is concerned.

This episode starts with House arriving at the office of his psychiatrist Dr. Nolan for his weekly session. Nolan can clearly tell that something is bothering House, but that he is reluctant to share it. Instead, Nolan has House tell him about his week, and House relates the tale of the amnesic patient. Alvie, House’s manic room mate from his stay in the mental hospital, also makes a return in this episode.

A young woman is brought to the ER with a complete loss of memory. She was found jogging down the middle of the street with no idea who she was. An MRI was obtained but was normal. The patient had no ID, just her heart rate monitor and clothes — expensive clothes, House mentions. He also deduces that she is an ultramarathoner from her general physique and metabolism.

House takes a closer look at the MRI and notes a region of that shows some “loss of differentiation between the grey and white matter” (grey and white matter are the two types of brain tissue). Chase points out that the area of the brain affected is the part that controls memory, so he doesn’t think it’s a coincidence. The differential diagnosis consists of bacterial infection, multiple sclerosis, a history of head trauma, or toxin exposure. House thinks that he can track down where she bought her heart rate monitor by its serial number. It’s possible someone will recognize her at the running store, or he figures that the store is likely to be close to where she lives, and the view might spark some memory. While no one at the running store recognizes her, it turns out that she’s a regular customer at the donut store across the street. Through them, House is able to track down the patient’s house and husband — none of which is recognizable to her. It turns out that her name is Sidney and she’s a high powered civil rights lawyer who spends almost all her spare time running. Her husband mentions that she recently won a settlement for some individuals who had been exposed to high levels of methane, and House thinks methane exposure might account for her symptoms. He takes her back to the hospital, but she trips in the yard, reporting that her foot has gone numb. She also loses bladder control. House suspects that she has developed partial complex seizures.

Back at the hospital, Sidney’s been under observation for twelve hours with no sign of any seizures. House tells the team to stress her more in an attempt to bring out any seizures, but his team tells him that she’s already under a great deal of stress from fighting with her husband. She suddenly becomes acutely short of breath and starts struggling for air. She is found to have pulmonary edema (fluid in her lungs) that appears to be related to diabetes insipidus (A condition where the kidneys cannot retain fluid correctly. This is a different from diabetes mellitus, or “sugar diabetes,” what most people think of when they hear “diabetes”). The diabetes insipidus is felt to be related to damage to her hypothalamus, making three separate areas of her brain affected. Taking in all the symptoms, House diagnoses the patient with spongiform encephalitis (more commonly called “spongiform encephalopathy.” It’s a rare type of infectious brain disease — the best known are Creutzfeldt-Jakob disease (CJD) and bovine spongiform encephalopathy (BSE), i.e “mad cow disease”).

House wants to perform brain surgery to remove the damaged tissue. Sidney is for it, but her husband is against it. The husband threatens a lawsuit to block the surgery. As the argument rages, House looks at the vitals sign monitor and tells them that it’s too late. The extreme variation in heart rate means that the spongiform encephalopathy has invaded her brainstem and now it’s too late for surgery. All that remains is to implant a pacemaker to control her heart rate, and then give her radiation and chemotherapy in an attempt to buy her a few more weeks of life. A short time later, Taub arrives to tell House that when they implanted the pacemaker, they saw signs of a rapidly progressive cardiomyopathy — which doesn’t fit with the spongiform encephalopathy diagnosis. The team continues to have trouble stabilizing her heart and she experiences fast heart rates and low blood pressure. Endocarditis (a type of infection of the heart) is suggested as a diagnosis, though House favors tuberculosis. Both of these possible diagnoses hinge on the fact that her immune system has been suppressed by her extreme exercise habits. He orders her started on a tuberculosis drug regimen.

Sidney continues to deteriorate. Her oxygen saturation is dropping and her pulmonary edema has returned. The team rushes her…somewhere…wherever it’s convenient to have a crashing patient, I guess. In the dim blue lighting of the hall, House notices a faded tattoo on her ankle. She had clearly tried to have it removed, but only the top layers were taken off – the rest remained. It suddenly all clicks for House. The extreme running has affected her immune system, causing her to become allergic to the tattoo ink, and that’s what is causing all her symptoms. Some surgery to remove the tattoo in its entirety and she’ll be fine — physically, at least. Her memory remains absent.

I have few specific medical complaints about tonight’s show. I thought the medicine was sloppy, with none of the suggested diagnoses fitting well – but then the actual medicine was clearly secondary in this episode. As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

Surgery for prion disease? Chemotherapy and radiation for prion disease? It’s not cancer; it’s a poorly understood infectious disease and none of these are appropriate treatments.

House first tries to convince us that her immune system has been suppressed from all her exercise – which is certainly a possibility. Then they turn around and state that her extreme exercise caused her to be allergic to something she has never been allergic before. In other words, it somehow gave her a heightened immune system. This is the opposite of what he had said a few minutes before, and farther from reality (remember that severe allergies are treated with immune suppression).

I notice the writers were being coy with which specific spongiform encephalopathy House thought the patient had. That way, they could borrow symptoms from several. Variant CJD seems the most likely, yet she has some symptoms that are closer to traditional CJD than vCJD.

Other than one episode of incontinence, she didn’t have any signs of diabetes insipidus.

There are frequently findings on the MRI with people with spongiform encephalopathy.

Amnesia almost always makes a good mystery, and this was no exception. I give the medical mystery an A-. The solution was clever, but didn’t make much sense as it contradicted earlier information. I give it a C. The medicine was sloppy and superficial. The superficiality I can forgive in an episode like this, but not the sloppiness: C-. The soap opera was the major part of this episode, particularly focusing on House and Nolan, House and Alvie, and the patient and her husband. It earns a solid A.

The review of the previous episode of House
A list of all prior House reviews

We’re in the middle of National Nursing Week and I’ve been saving this Careers in Nursing public service ad for just such an occasion.

I’ve always made it a point to get along well with nurses. They’re fellow medical professionals, and as a physician, they can make your life easy, or they can make it a living hell. Personally, I always preferred easy — and it always just seemed common sense to never antagonize the nursing staff.

Here’s a quick true story from residency to prove my point: As a first-year resident, we spent a month working in the NICU (neonatal intensive care unit). When we were the NICU resident on call, one of our responsibilities was to manage the ventilators many of the newborns were hooked up to. (It was a big hospital, with probably 30 to 40 babies at any given time, with at least half of them intubated and on the ventilator.) To do this, a lab known as a blood gas would be drawn, and based on the results, you’d adjust the ventilator settings. This probably occurred forty times during a night of call. Generally, the nurses were very helpful and would wait until they had about a dozen blood gas results before giving you a call. This was to allow you time to catch some sleep in the call room.

However, one of my fellow residents did something that annoyed the nursing staff, and then when called on it, acted very arrogantly. This was not a good idea. In retaliation, when it was his night to be on call, they would page him every single time a blood gas came back instead of holding on to the resultsand calling every few hours. In eight hours of call, he would receive forty pages (or about one every twelve minutes) from the nursing staff alone. The poor idiot never got any sleep on call. Sadly, I don’t think he learned his lesson, and continued to have problems with the nursing staff all the way through residency.

Click on the image for the full ad

This PSA appeared in DC comics from April 1957. The script is by Jack Schiff and the art is by Ruben Moreira.

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Black Canary is on a mission to rescue Katy, a five year old girl who has been kidnapped. It turns out there’s a slight medical complication:

Katy suffers from a ventricular arrhythmia. In other words, her ventricles — the lower chambers of the heart — are beating abnormally. This can be a real problem because the ventricles are the workhorses of the heart: they do most of its work by pumping blood through the lungs (right ventricle) or throughout the body (left ventricle). If something is going wrong with the ventricles, it’s not good.

In particular, Katy has ventricular tachycardia (i.e. “V-Tach”), a condition where the ventricles are beating independently of the atria (the top of the heart) and beating way too fast. This is unfortunate for a couple of reasons: first, the ventricles are pumping so fast that they don’t have enough time to fill up before contracting, so blood is not getting moved around the body efficiently which can lead to heart failure (which probably explains why Katy is having shortness of breath. Well, that and being out in the freezing cold in her pajamas). Second, and more important, is that ventricular tachycardia is an unstable rhythm and can quickly degenerate into ventricular fibrillation or asystole (flatline). These rhythms, as my old cardiology instructor used to say, are “not compatible with life.”

So how do you treat ventricular tachycardia? If it comes on suddenly, like in a code blue situation, then you bring out the defibrillator paddles and shock the heart back into a normal rhythm (hopefully). For long term control, antiarrhythmic drugs are often used. As the name suggests, the medications keep the heart in a normal rhythm and out of arrhythmia. They can be nasty drugs with many side effects (including, ironically, causing arrhythmias) so they aren’t used unless absolutely necessary. In this case, Katie is on Flecainide to prevent her tachycardia from recurring.

Tags: comics medicine black canary birds of prey arrhythmia ventricular tachycardia flecainide gail simone

A solid outing on Fringe this week. I’m looking forward to next week’s season finale.

The Plot: The episode starts at Fringe headquarters in the alternate universe. A major breach is detected and a team – consisting of Olivia, Charlie, and team leader Lincoln Lee — is sent to an old theater to evaluate. The breach is substantial enough that the Fringe team plans to quarantine it, an act that will somehow cause hundreds of thousands of casualties. At the last minute, the quarantine is called off after the breach seals itself. Scouting the theater, the Fringe team finds a dead body with “multiple carcinomas” (sound familiar?) A search of the body reveals a drivers license and a twenty dollar bill, which they take to be a forgery because they’ve never heard of Andrew Jackson. Meanwhile, watching hidden from a few rows away are the Olivia and Walter from our universe, plus two others.

Thirty six hours before, Olivia is drowning her sorrows in a bar when an Observer drops off a note for her. Walter watches a video of Peter agreeing to cross back to other universe with alternate Walter and is disconsolate because he knows there’s something important about Peter that he’s supposed to remember, but can’t. When Olivia shows him the note, he realizes this is what he was trying to remember: Peter is somehow going to destroy the universes. He recalls one of the Observers warning him once never to let Peter cross back to other side, and this is why.

Walter and Olivia decide they need to cross over to the other universe and retrieve Peter. They head over to Massive Dynamic, because a sketch on the page the Observer gave Olivia looks like one of William Bell’s machines, but the team there knows of no way to cross over without suffering severe molecular damage. Walter theorizes that the Cortexiphan children could cross over safely, but Olivia is the only one who is mentally stable. Agent Broyles reveals that there are more stable Cortexiphan children: James, Sally, and Nick. They agree to help Walter and Olivia cross over to the other universe.

Meanwhile Peter wakes up in a hospital bed. He walks downstairs to find his mother — his actual mother — cooking him breakfast. They have a nice chat.

At the theater in our universe, the four Cortexiphan children form a circle with Walter in the middle. He leads them through a concentration exercise when suddenly James collapses, tumors forming on his skin. He points to a blimp that can be seen through the skylight as proof that they’ve crossed over. They hide as the alternate Fringe team arrives in force, just as in the beginning of the episode. Because of what they’ve found, the alternate Fringe team is brought before the Secretary, other Walter, who tells them his version of what happened. He explains to them that a group from the other universe has crossed over and needs to be found before they can start a war.

Over breakfast, Peter’s mother gives him some notes that alternate Walter left for him. They are for a project he would like Peter’s help with. As he looks through them, the plans are recognizable for the strange machine on the note left by the Observer.

Meanwhile, what’s left of our Fringe team is heading to Central Park to meet up with William Bell. When they arrive at the meeting place, there’s no Bell to be seen. A few seconds later, the alternate Fringe team, with several busloads of additional agents, show up. Nick is shot and killed and his girlfriend Sally uses her pyrokinetic powers to cause a fireball, consuming herself and Nick and severely burning the leader of the alternate Fringe team. Walter runs off, but is shot. He stumbles on and eventually collapses in front of a hospital. Olivia escapes, and uses a convenient street side white pages terminal to track down where alternate Olivia lives. As she is covertly spying on her double, William Bell appears and asks her to trust him, warning her that Walter is in trouble.

1. Bullfinch
There were a number of allusions to the two-years of Fringe mythology we’ve been building up.
The return of the Cortexiphan children
Alternate Charlie clearly never fully recovered from his first-season encounter in Unleashed.
A mention of the ZFT Manifesto (its first mention this season — they still need to explain the missing chapter, though).
And of course, the return of William Bell.

2. Vive La Différence
I liked how the blimps (as I’ve said before, you can never go wrong with blimps — well, except the Hindenburg), the Nixon silver dollar, the Martin Luther King Jr. twenty dollar bill, and the West Wing poster all clearly set the alternate universe apart from ours — in addition to its more militaristic stylings. I’m somewhat creeped out that Cabbage Patch Kids are still a big thing over there.
And how could I forget mentat Astrid?

3. Cellular Biology vs Molecular Biology vs Chemistry vs Physics
My only complaint about the science is a nitpick, when Brandon, the Massive Dynamic scientist, explains that the cells are separating on an atomic level. Once you’re dealing with individual atoms, you’re well past the cellular level.

4. Susan?
I know that Nick is from Bad Dreams and James is from Olivia, In the Lab, With the Revolver. I’m not sure where Sally is from, unless she’s somehow tied into the pyrokinetics from The Road Not Taken.

5. Let’s Be Frank
Clearly something is up with alternate Olivia’s significant other, the way they keep referring to his “last night.”

A nice solid episode that advanced the story greatly, but also tied into many old plot points. The Fringe Doomsday Clock regains a minute this week.

Tags: television fringe alternate universe peter war cortexiphan

House Challenge is up to date as of last week, just leaving the final week of competition.

Overall, TRad and Noether continue their dominance, with 95 and 87 points respectively. Corien is in third with 74 points, followed by Theta Sigma with 65 and The Erskine with 60 points.

Click here to see the full scoreboard.

Another scene with psychic nosebleed king Maxwell Lord, this time from Justice League: Generation Lost #1 (Winick, Giffen, Lopresti).

All previous Psychic and Superpowered Nosebleed Zen posts.

Tags: comics medicine nosebleed maxwell lord justice league

The Season Finale of House, Season Six, and it summed up the season in a microcosm: moderately interesting case and uninspired medicine all sacrificed in the name of soap opera.

There has been a crane collapse in Trenton and Cuddy rushes over to lend a hand. House heads over too for reasons of his own, most of which have to do with Cuddy. They spend most of their time triaging victims (deciding who needs treatment first, and who can wait). House diagnoses one person with a skull fracture noting that she has a Glasgow Coma Score (GCS) of 11 (a “moderate” brain injury). He tells Cuddy that her patient is unlikely to survive, so not to waste resources on him. Cuddy agrees, telling the paramedics that the patient is expectant (expected to die — and he does die a short time later).

Foreman is treating the crane operator, who apparently fell asleep on the job. House finds a stash of caffeine pills in the operator’s pocket; he says he was taking them plus drinking coffee – something he doesn’t normally do — all in an attempt to stay awake. Given the fact that the operator fell asleep despite all the caffeine he was consuming, House suspects there is an underlying neurological problem. He has Foreman take the operator back to the hospital to evaluate.

Later, sitting by himself, House hears a clanging sound from deep in the rubble. He alerts the other rescuers, but they can’t find anything. Undaunted, he crawls into the rubble himself and finds Hanna, a woman whose leg is pinned by a heavy beam.

Back at the hospital, the team’s initial diagnosis of the crane operator includes vasovagal episode (a fainting spell), sick sinus syndrome (the heart’s natural pacemaker is not working correctly), or a meningioma (a tumor of the membrane that surrounds the brain). Taub believes the operator simply fell asleep on the job. House suspects a space-occupying lesion (like a hematoma, abscess, or tumor), so orders an MRI.

The paramedics cannot get an intravenous line in Hanna, so House places an intraosseous line (where IV fluids are directed into the bone marrow instead of a vein). It becomes clear that Hanna is trapped by a support beam, so Cuddy and the paramedics recommend amputating her leg or risk crush syndrome (basically, when muscle is crushed it releases a bunch of toxic substances. As long as the muscle remains trapped, these toxins are sealed off from the body, but once the crush is relieved, all the toxins come pouring into the rest of the blood stream causing kidney failure and other serious problems). Hanna will have none of it and House convinces them to give it a few more hours to remove the rubble over the beam. He promises that they will not need to cut her leg off. House wants to head back to the hospital, but Hanna has a panic attack being left alone, so he stays.

The MRI is normal, but the crane operator starts bleeding from both the nose and eye, suggesting something is wrong. Chase thinks that he has a brain infection — but he’s not showing any fever, so House favors a venous sinus thrombosis (a clot in the large veins that drain the brain) and wants the team to perform a venogram.

An attempt is made to lift the beam off Hanna’s leg. It seems to work at first, but a secondary collapse occurs and her leg is still trapped. Furthermore, she suffers a tension pneumothorax (a dangerous type of collapsed lung), which House relieves with a needle thoracostomy.

The venogram is normal, but now the operator is running a fever. The new differential includes a subarachnoid bleed or meningitis. House orders a lumbar puncture.

Cuddy tells House that it’s time to face reality: they need to amputate Hanna’s leg. House insists he can buy her more time by treating her elevated potassium with glucose and insulin. However, in the end, he agrees with Cuddy, and climbs into the rubble to tell Hanna that her leg must be amputated to free her. He tells her about his leg injury and how he wishes his leg had been cut off. She agrees to the procedure, and House performs the amputation himself, getting her free of the rubble. He climbs into the ambulance alongside Hanna and her husband for the ride back to the hospital, leaving his cane behind.

The spinal tap was normal, but now the patient is in a coma. House realizes that his symptoms (passing out, bleeding, coma) always occur at times of elevated blood pressure. From this, he deduces that the patient has an arachnoid cyst on his lower spine. He is about to order a CT scan to confirm when

Hanna starts to have trouble breathing and her blood pressure is dropping rapidly. A quick exam shows no evidence of pneumothorax (collapsed lung) or tamponade (bleeding into the sac around the heart), so he deduces that she has a pulmonary embolism (blood clot in the lung) from being trapped in the rubble for too long. He gives her Streptokinase, a thrombolytic (drug which dissolved blood clots), but when he sees no response, he realizes that she must have a large fat embolism (a clot made up of fat), which can be a complication of orthopedic surgeries such as an amputations (or caused by the trauma itself). Unfortunately, there is little that can be done for a fat embolism and Hanna dies before she can get to the hospital.

Dispirited, House returns to his apartment and grabs the Vicodin bottles he has stashed there. He is sitting on the floor, contemplating taking the medication, when Cuddy walks in and tells him that she has called it off with Lucas…

Most of tonight’s medicine was trauma medicine, and area I (thankfully) don’t practice much in. I’d like to hear what any emergency physicians, paramedics, or EMTs thought. As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

Streptokinase is not routinely carried on ambulances. ( I say “routinely” only because I know there have been a few studies run on pre-hospital thrombolysis in myocardial infarctions, but they use more modern thrombolytics.)
Recent surgery is a relative contraindication to thrombolytic use (as opposed to an “absolute contraindication”, so it can be used if it is felt that the benefits outweigh the risks – but remember, we have no idea if Hanna suffered other injury from the collapse. She very well may be bleeding internally.
Thrombolytics time to work; they’re not immediate.

House didn’t cure her tension pneumothorax, he merely converted it to an open pneumothorax. A less dangerous situation to be sure, but still a collapsed lung.

High potassium is not the only toxin in crush injuries — though it is probably the main one, or at least the one of immediate concern.

Spinal arachnoid cysts present with spinal cord compression symptoms (if they have symptoms at all). Blaming one for unconsciousness, coma, and bleeding from the nose and eyes is quite a stretch. A cyst large enough to cause problems like that would have demonstrated spinal cord symptoms long before.

ABCs. They should have intubated her as soon as she had trouble in the ambulance. It may not have saved her life, but it could have bought her time. You can deliver a lot more oxygen by endotracheal tube than by face mask.

Glucose + insulin is a valid way of dropping an elevated potassium in emergency situations (though at this point, she was still trapped, so worrying about treating the hyperkalemia is premature)

I know of no hard and fast rules about how long you wait in a crush injury before amputation, other than that amputation is considered the treatment of last resort, used in immediately life threatening situations (building on the verge of collapse, for instance).

I’m not sure I buy his statement that he can’t put her out because it will depress her respirations too much. True, she has a pneumothorax, and she’s in a difficult location to keep a close eye on, but surely they can give something stronger than what they gave her.

The medical mystery of the crane operator was interesting, but only made up a small part of the episode. Still, I give it a B+. The solution was quite a stretch and only deserves a measly D+. The medicine in the hospital was pretty good, even if the solution was poor. I have some serious concerns about the medicine in the field, especially the need for an amputation at that point (and even earlier, when Cuddy originally suggested it), and the use of Streptokinase. Overall, I give it a C. The soap opera was good, though it needed more Wilson (and more Foreman — he really got ripped off this season); I give it a B+.

The review of the previous episode of House
A list of all prior House reviews

House Challenge scores have been updated as of last week’s episode. Final scores should be up tomorrow night.

Diagnosing a patient is hard enough in the real world (that headache, is it a tension headache? migraine? meningitis? Strep? brain tumor?). Just imagine how much more difficult it would be in the world of comics, where psychics, aliens, strange drugs, and mutations all come into play.

Still want to be a comic book doctor? Here’s your chance, with four more comic book medicine case studies:

The previous case studies and a bit more an explanation can be found at Dr. Scott’s Case Studies of Comic Book Medicine

This week’s episode was a bit of a letdown after last week’s Over There, Part 1 (and the several great episodes leading up to it). It wasn’t bad, but it wasn’t terribly good — or very Fringe-y at all. It seemed like it was an episode designed to get everyone in place for next season, rather than a fitting ending for this one.

The Plot: Olivia and Bell are searching hospitals, trying to find Walter. Olivia sees the alterna-Fringe team arriving and realizes that they must be in the right hospital. Bell stalls them while Olivia finds Walter and escorts him out of the hospital.

Peter meets with his father, who tells him that he wants to repair the rift and save both universes, but that he’ll need Peter’s help. He asks him to take a look at the power source for his “fix-the-rift” device ( power source that looks amazingly like an original XBox).

Walter, Olivia, and Bell stop just long enough to shill for Kentucky Fried Chicken, and then they head out again. Walter and Bell are off to Walternate’s old Harvard lab to build a device to let them cross back over into our universe while Olivia heads back to the city to look for Peter.

Alterna-Olivia has questions for the Secretary of Defense and he admits that yes, the people who crossed over are our doubles, only evil (or, more correctly, eeeviiilll). Sensing a connection between her and Peter, he asks her to escort him to his new apartment. Alterna-Oliva arrives back at her house, only to find Olivia waiting for her. They exchange some family history (Mom dead? No? Sister dead? No? Niece?) before getting to the inevitable fight. Alterna-Olivia is the stronger fighter, but Olivia decks her with a convenient piece of wrought iron. She then cuts and dies her hair so that she looks just like alterna-Olivia. Just about this moment, alterna-Charlie shows up at her doorstep and tells her that there’s been a power surge in Walternate’s lab and they’re supposed to check it out. Olivia tells him they’ve got a new mission, and that’s to move Peter to safety. They arrive at Peter’s apartment and Olivia warns him what Walternate is up to. Alterna-Charlie realizes something’s wrong with Olivia, but not in time to stop himself from being clobbered. After hearing his father’s plans, Peter tells Olivia he doesn’t belong in either universe — but then she kisses him and poof! — problem solved.

Olivia, Peter, Walter, and Bell arrive in front of the theater where they crossed over in the previous episode. A minute later, the alterna-Fringe team arrives. Peter and Walter move his machine inside and set it up while Olivia and Bell hold off the alterna-Fringe. The battle is chaotic, and at one point Bell finds himself confronted by two Olivias — and then clobbered by one of them. When he comes to, he finds the battlefield in flames and Olivia tells him she had to use one of his experimental grenades to save their life. The two of them hustle inside the theater to meet up with Walter and Peter. Walter is still complaining that they won’t have enough power to cross over, but Bell tells him not to worry. Bell explains that he has crossed the dimensional gap so many times his structure is unstable, like trillions of atom bombs, and he will provide the power for crossing over, even though it will cost him his life. The machine is activated and Peter, Olivia, and Walter cross back into our dimension.

A little while later, as Astrid is fattening him up with pie, Peter tells Walter that he’ll stay around for at least a little while. Meanwhile, it becomes apparent that the Olivia who crossed over was actually the Alterna-Olivia, and the real Olivia is locked up in the alternate universe.

1. And Flash Gordon Was There in Silver Underwear
I have to give alterna-Olivia props for her great choice of ring tone on her home phone.

2. Watch It Wiggle
The Quarantine Zones looked like the Jell-O bus from Fringe’s third episode “Ghost Network”

3. Answer Me That, Mr. Green Lantern
The show continued to hint at the subtle differences between the two worlds. I wish I had been able to see more of the comics that were framed in Peter’s apartment, but here’s the one I did catch:

That’s the original cover to Green Lantern #76 (April 1970, cover by Neal Adams) on the left, and the alterna-version on the right.

4. Full Stop
I’m sure it will be hand-waved away with mentions of “door stops” and William Bell’s atom power, but Walter seemed quite insistent that they needed Olivia’s abilities to cross back over. Does alterna-Olvia have the same abilities, or was that just papered over? In other words, was alterna-Olivia exposed to Cortexiphan too?

5. I Thought They Were Twins
Is there anyone who didn’t realize that was alterna-Olivia who helped Bell up? There was nothing even remotely subtle about it. And it never crossed Bell’s mind — who had just seen two Olivias — that this may be the wrong one? (Yes, I’m sure it will be handwaved away because she “knew about the grenade” — but maybe alterna-Olivia, unlike real Olivia, actually has some investigative skills).

6. Frankly My Dear
They never did explain Olivia and Frank’s “last night” comments from last week’s episode.

Not a bad episode, but rather anti-climactic compared to the last several. The Fringe Doomsday Clock stays in place and ends the season at 11:56

Tags: television fringe alternate universe peter olivia

UPDATE: Here’s the other alternate world comic book covers:


The originals are Crisis on Infinite Earths #7 (with Superman holding a dead Supergirl), Superman #75 (”The Death of Superman” — the “Collector’s Cover” shows a bleeding Superman symbol), Justice League #1 (with Guy Gardner instead of Jonah Hex), and Batman: The Dark Knight #1 (”The Dark Knight Returns”).

From DC’s “The Source” blog.

scene from All-Star Comics #8

Despite having superior medical skills and technology, it seems the Amazons suffer the same inability to wear head mirrors correctly as the rest of the comic book world.

For today’s comic book public service ad, we welcome back Binky and his younger bow-tied brother Allergy. Today’s lesson deals with not being afraid of innovation, and Binky compares his brother’s soap box derby car to the Wright Flyer. (Though I’m not sure that’s a good idea because if Allergy gets airborne in his car something is seriously wrong….)

Click on the image for the full ad

Further Reading: Soap Box Derby Scandals

This PSA appeared in DC comics from August 1955 — this particular copy comes from Adventure Comics #215. The script is by Jack Schiff with art by Win Mortimer.

More PSAs

Tags: comics psa binky allergy jack schiff win mortimer

Click on the image for the full ad

A second of a series of old comic book ads featuring famous detective Sam Spade selling out for advertising Wildroot Hair Tonic. Clearly written in the era of “It’s the Commies!”

From Adventure Comics #147 (December 1949)

Ever wonder what happens to all the sick and injured fish in the ocean? It turns out that Aquaman has a medical clinic where he treats them all¹. A whale with bruised ribs? A swordfish with a broken nose? Come see Dr. Aquaman!

Aquaman is called when a sick sea-lion is spotted. He immediately diagnosis it with “Fish Scurvy” because of its glassy eyes². He mentions that this is a highly contagious disease³ and then brings the sea lion down to his clinic⁴ and places him in a glass isolation cage. He posts a sign⁶ on the cage which says “Warning! If opened will infect area of 100 yards!”

Meanwhile the coast guard informs him that a gold smuggler has been seen nearby. The smugglers try to outsmart Aquaman: they find his clinic and break open the cage, releasing the sick sea lion. The entire area, for 100 yards in every direction⁷, is under quarantine. They quickly speed away, knowing that Aquaman would never break quarantine and risk infecting more fish. But this is Aquaman we’re talking about, and he never lets the bad guys escape. With the help of his finny friends, he hides the signal lantern the smugglers are following (with squid ink and blow fish) and has them follow a fake one (a lantern fish), leading them right back into the quarantine area where he captures them⁸.

NOTES:
1. There are at least ten doctors in my town of 30,000 and we’re nearly always booked solid. How can one man, even if he is Aquaman, treat every fish in the sea? Maybe he franchises.
2. Aquaman of all people should realize that a sea lion is not a fish.
3. Nor is scurvy contagious, it’s a vitamin deficiency.
4. The sea lion is pretty isolated already, why not treat him there, rather then bring a contagious animal down to the clinic in the middle of the ocean?
5. As mammals, sea lions need to breathe air regularly. Keeping him in an underwater glass case would not be conducive to his survival.
6. Who is the sign for? The fish can’t read – the sign is only there to hand the smugglers an escape plan on a silver platter.
7. Apparently the ocean currents flow 100 yards in every direction, and then suddenly stop.
8. I never had any doubt that Aquaman would catch the smugglers, but what about the sea lion? Did he survive? Did Aquaman cure him? Were other “fish” infected as well? This would have made a better end to the story then a few tied-up smugglers.

Last Thoughts: Scurvy
I’m sure the writer was just trying to come up with a clever sounding name when he chose “Fish Scurvy,” but it turns out to be an actual disease. And a cleverly named one at that, being scurvy that occurs in fish.
Scurvy is caused by a severe deficiency is Vitamin C. Symptoms start with appetite loss, poor weight gain, diarrhea, and tenderness and discomfort in the legs. Bleeding, especially of the gingiva (guma) and eyes, is common. Bone and cartilage deformity occur. Scurvy is fatal is not treated — and the treatment is simple: lots of Vitamin C.
Most animals make their own Vitamin C so are not susceptible to scurvy. Only a relatively few do not produce Vitamin C and need to eat some regularly in their diet. These animals include bats, guinea pigs, and certain primates (including humans). Some fish and birds also need Vitamin C to survive.
On the other hand, sea lions make their own Vitamin C, so can’t catch scurvy. In fact, they have plenty of Vitamin C and seal and sea lion meat was eaten by Arctic explorers to treat scurvy.

Calling Dr. Aquaman is from Adventure Comics #188. The writer isn’t listed, but the art is by Ramona Fradon.