Polite Dissent

Sapramiska had the high score this week with 15 points, followed by alice, Dean, lionel_m, and Silvinia all with 8.

Overall, Sapramiska takes the lead with 16 points, followed closely by lionel_m with 14 points and Chaya with 13 points.

Click here to see the full scoreboard.

A better episode of House this week. The mystery and medicine was better, and the soap opera had settled down to a dull roar.

In the study in her Gothic house, Alice, the famous writer of the Jack Cannon series of young adult detective fiction, puts the finishing touches on her latest novel, then locks it away in her safe. She makes a little small talk to a teenaged boy in the room with her, and then acknowledges that he’s no more than a figment of her imagination. She opens the drawer to her desk and pulls out a pistol and holds it to her mouth. Just as she is ready to fire the gun, she has a seizure. The guns goes off early, just grazing her cheek. Upon hearing the gunshot, her maid runs in and Alice is rushed to the hospital.

House takes it upon himself to examine Alice in the Emergency Room because he is a huge fan of her books. After he accuses her — correctly — of attempting suicide, she tries to leave the hospital, but House has her placed on a seventy-two hour psychiatric hold. He calls the team in to examine her and then monitor her for another seizure. They find her an extremely unpleasant patient to deal with. Meanwhile House and Cuddy head out for a date that is actually an evening of poking though Alice’s house for clues. They talk to her maid and learn that Alice has been having a great deal of back and hand pain recently. They also learn that she eats several cans of tuna fish every day. House is unable to open the safe to find her latest manuscript, but is able to take the typewriter ribbons from which he hopes to suss out the novel.

Back at the hospital, neither Foreman nor Taub have seen any seizure activity. House arrives and shows them that Alice is sweating profusely, but only on one side of her body. Given all her tuna consumption, the team suspects that she has mercury poisoning, but the initial tests all come back negative. Nevertheless, House wants to go ahead and start her on chelation therapy while obtaining the definitive tests, but has Cuddy go in since Alice has asked for a female doctor. A short time later, after Alice fires her maid and makes snide remarks to Cuddy, she tells them she wants the male doctors back. When Taub and Chase arrive to set up the chelation, she reads Chase like a book. When she is asked to what she thinks of Taub, she remarks that he reminds her of her ex-husband and suddenly develops a severe headache and dangerously elevated blood pressure. Chase thinks it is a reaction to the chelation medication until Taub point out he hasn’t started it yet.

Alice is having symptoms of pain, seizures, and hyperhidrosis, along with episodes of elevated blood pressure. Mercury poisoning has been ruled out. Hemolytic uremic syndrome is mentioned but quickly dismissed. House points out that both of her severe episodes (the seizure and the high blood pressure) occurred at times of stress. He wonders if it may be an issue of excess adrenalin. This suggests the diagnosis of a pheochromocytoma (an adrenalin secreting tumor). The team tries to get an MRI, but the magnet in the MRI machine rips out the surgical screws in her leg — metal screws she had apparently deliberately not told the team about — causing severe burns and tissue damage.

House decides to try a different approach. He goes to Alice and tells her that she’s been going about suicide the wrong way as gunshots are painful. He offers her access to a painless lethal drug if she’ll cooperate with the team. She agrees, and when he gives her the syringe to hold onto for later, she immediately injects it into her leg. Of course, it wasn’t a lethal drug, but instead a sedative. It allowed the team to obtain a PET scan, and also allowed House to extend her psychiatric hold for another 24 hours. The PET scan is negative. However an ultrasound obtained the next day shows a pericardial effusion (fluid build up in the sac around the heart). To the team this suggest something viral or cancer. House takes a different approach, he looks at the character of “Helen” in her novels — the characters that he believes to be an analogue of her. Helen suffers from pain, fatigue, light sensitivity, and depression. When combined with Alice’s symptoms, these strongly suggest a diagnosis of lupus. Tests are run, which apparently are negative as they are never mentioned again.

Later, after Cuddy complains of seatbelt-related neck pain from an evening of go cart racing, House wonders if Alice is suffering from thyroid damage from a seatbelt injury from a long ago car accident — the same one that injured her leg. She gets angry during their discussion and develops suddenly paralysis –- which doesn’t fit with House’s hypothyroid hypothesis. Taub suggests that she may have a trauma-related syringomyelia. The symptoms fit, but she is refusing any further testing or treatment. Finally, with some help from her old medical records, House is able deduce what happened. She has a syringomyelia from the accident, but more importantly, her son was killed in the accident, and she blames herself for his death. House tells her that she is not at fault for her son’s death — he points out an aneurysm on his autopsy report that shows he was likely already dead at the time of the accident. Relieved of the burden, she agrees to begin treatment.

As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

The team kept listing “hyperhidrosis” as a symptom, but kept leaving off the most important aspect — that it was only one-sided. House made a big point of this when he showed it to Foreman and Taub in the first place. This screams “neurological cause,” but it was never addressed (or even mentioned that way again). Based on this symptom alone, they should have made the correct diagnosis, or at least found the correct organ system, much earlier.

There is no such thing as a National Records Archive that stores everyone’s medical records. Each doctor/hospital keeps their own. Yes, an organized central system might make it easier to track down a patient’s medical history, but it would also be a privacy nightmare.

How does the syringomyelia explain the pericardial effusion?

It’s generally more involved than that to get a patient admitted on a psychiatric hold (it varied by state). Unless there is some urgent medical reason, patients on a psychiatric hold are placed on a psychiatry ward. If their medical condition prevents this, then they are carefully monitored, i.e. someone is in the room watching them at all times. And this would not include House or his team.

I find it hard to believe that anyone could live for 10 years with hypothyroid symptoms that severe. That being said, she did remark she hated doctors, so that may explain why she hadn’t sought care.

A PET scan is negative, and so now they’re going to ultrasound her entire body?

Not to beat a dead horse, but a halfway decent physical exam would have revealed the surgical scars on her shin and the likelihood of an orthopedic repair. A quick x-ray would have confirmed metal pins. At our facility, if the radiologists even suspect some metal in the patient’s history at all, x-rays are ordered.

Another good medical mystery this week, I give it a B+. The final solution was logical and fit most of the symptoms, more than usual anyway. It also earns a B+. The medicine overall was much better this week with an almost logical procession from diagnosis to diagnosis and less jumping around. It deserves a solid B. The soap opera remained good, but I don’t think it was as strong as the previous two weeks: B.

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

Let me take a moment to recommend the excellent comic book series Unwritten. It may share a name and some superficially similar themes to tonight’s episode, but it is a much deeper (and more enjoyable) look at reality versus fiction. What it the Jack Cannon figure Alice was imagining was real — or at least thought he was — and didn’t realize he was actually a fictional character? And what would this mean for other fictional characters. The comic is published by Vertigo (part of DC comics), though several collected editions are available.

Another library-themed public service ad — and in this one, at least, the kids are learning for themselves. There’s no C-List superheroes to coax kids to read, or crusty old sea captain to…well, frankly, I don’t know what he’s got to do with reading.

What if it’s Sports, Science, and Animals — say breeding better thoroughbreds through genetics. Then where is it shelved?

(I apologize in advance) Back of the first panel: Invisible Bike.

This PSA can be found in DC comics from June 1962, in the waning years of DC’s PSA program.

The script, as usual is by Jack Schiff, and unless my eyes deceive me, the art is by Sheldon Moldoff. His PSA art was never as bright or cartoony as other PSA artists (but not as dark as Bernard Baily’s), and he’s one of the few who’d include foreground action (the high jumper, in this case) in the ads. (Update: The GCD agrees that the artist is Moldoff.)

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Tags: comics psa library books moon jack schiff sheldon moldoff

An excellent episode of Fringe tonight, one of the best yet.

The Plot: On a busy sidewalk in Hoboken, a man is standing slightly off to the side, making jerky counting motions with his hands, and watching the movements of a particular woman as she makes her way down the street. He walks up to a nearby mailbox and balances a pen on top of it. When passing traffic knocks the pen down, it leads to a Rube Goldberg-esque scenario that ends with a city bus fatally running over the woman.

Fringe Division is called in because this is the second similar accident in two days and that strikes the Division as anomalous. The accident seems to be just that, an accident, until Agent Lee notices the pen, which catches his attention. In this universe, everything is digital, so no one past elementary school uses a pen anymore. A look at the photos from the first accident also show a similar pen. Despite the pen link, Astrid’s number crunching suggests the similarities are just coincidental — until a third accident happens. The Fringe team arrives to find a bus has just hit a car, but with no fatalities this team. No pen can be seen, at first, until Agent Dunham notices one rolling from under the car and that’s when she realizes the scenario is still going on. Sure enough, a passerby is not paying attention and walks right into the path of an ambulance, killing him. Dunham spots the guy responsible and draws a gun on him, but he is able to jump off a pedestrian overpass onto the top of a truck that just happened to be passing through at that exact moment (to avoid a bicycle he had thrown on the road) and he escapes.

Agents Dunham and Francis are able to tie the victims to a particular research hospital. They interview the medical director of the hospital who tells them that the hospital has been experimenting with nootropics –“smart drugs.” These drugs were given to people with IQs below 65 in order to make them more intelligent. It seems the drugs worked too well. Milo, The particular person Fringe is after was a patient in the smart drug trial and the medicine geometrically increased his intelligence. The final stage of the experiment was to take the patients off the smart drugs to return them to their baseline, but Milo has skipped this and has been systematically killing the people who are in charge of taking him off the medications. The Fringe team learns Milo’s address and talks to his sister. Through her, they learn he will likely be staying at a downtown hotel. Dunham and Francis debate whether going to the hotel is a trap since Milo always seems to be one step ahead of them, but Dunham decides to risk it anyway.

Meanwhile, Milo has used his abilities to predict Dunham’s death. When she arrives at the hotel, Milo leads her on a chase designed to bring her to the location where he foresaw her death. Fortunately, the quirk of real-Dunham’s not quite complete memories of Fauxlivia allows her to avoid the death Milo predicted, and she and Francis are able to capture him and bring him into Fringe custody.

1. Universal Differences
The US went to war with Aruba (I’m going to guess it had something to do with Natalee Holloway).
Smallpox is still an issue, though as previously discussed, they ensure everyone is vaccinated against typhus.

2. Not so Smart Drug
I can’t help but wonder if the smart drug being tested was Cortexiphan.

3. Altered States, Redux
I liked that Walternate’s plan includes the use of a sensory deprivation tank, which brings us back full circle to the very first Fringe episode.

4. Misty, Water-Colored
For my taste, Peter’s last appearance was a little too much “hammering the point home” that Olivia survived because she wasn’t Fauxlivia. It didn’t take Milo to predict that this was how Olivia was going to survive the episode — who didn’t see it coming?
Speaking of that, how was the Compromised Air Quality Protocol not in Fauxlivia’s memories. I can understand Olivia, earlier, not realizing a code was needed as that was new, undoubtedly since Fauxlivia’s “memory cells” were collected. But the oxygen protocol? Surely that’s older than a month.

5. Board Now
In the real world, researchers don’t return patients to baseline if there is a clear benefit of the therapy being studied. Of course, this is Fringe (where clearly they don’t believe in IRBs), and alternate-universe Fringe, which appears to be even worse.

This was a great episode, probably one of the best ever. I wish they all were this good. It was good enough to buy back two minutes on the Doomsday clock.

This week’s Fringe cipher was: BREACH.
A list of all previous Fringe reviews is available here.
Karl has much more to say.

scene from Cable & Dedpool #9

As this issue begins, Cable has just created his floating city utopia and the military has sent an armed response. He was able to defeat the planes and missiles easily — at the cost of a nosebleed — and now is calling up Nick Fury for a chat.

All previous Psychic Nosebleed Zen posts.

Tags: comics medicine nosebleed cable nick fury

Tippi had the high score this week with 13 points, followed by dynamiteHeaddy, Fran, Gary, and Udabac who all scored 12 points.

Overall, there is a tie for first place between Gary and Tippi, both with 22 pints. Fran is second with 20 points. Sapramiska drops to third with 19 points, and lionel_m is in fifth with 17 points.

Click here to see the full scoreboard.

A solid episode of House this week with a satisfying twist in the diagnosis at the end. Still, there were several large holes in the medicine. And a new doctor on the team — a psychiatrist.

Margaret is a 30 year-old woman, watching television at home alone, when she hears a suspicious noise. She gets up and finds the front door unlocked and open. She starts carefully creeping through the house, trying to figure out if something is amiss. She calls her husband and he tells her that he’s almost home, but if she’s really concerned, to head to the neighbors. She hears a slamming door and, panicked, runs to the front room — only to discover that it was her husband coming home. There’s no time for reassurance, however, as she immediately started uncontrollably vomiting and develops severe abdominal pain.

Margaret is admitted to the hospital for evaluation of her abdominal pain and vomiting. Prior to admission, she had several days of milder abdominal pain, but no vomiting. She also has slightly elevated LFTs (liver function tests). Before the team can really get started on suggesting possible diagnoses, Chase introduces the doctor he just hired to replace Thirteen: Dr. Kelly Benedict, a very attractive psychiatrist. Once introductions are made, the grilling of Dr. Benedict begins (or “pimping” as it is known in medical school) and it is clear that she is out of her depth. Her suggestions of hepatitis A and appendicitis are quickly discredited, and the team concentrates on the possible diagnoses of lead poisoning and hepatic fibrosis. A liver angiogram is ordered to look for fibrosis, and Foreman and Taub head off to search her house for lead.

The angiogram shows no fibrosis, but it does reveal a narrowing in part of the liver, apparently from old scar tissues. Old broken ribs are also seen on the study. The investigation of Margaret’s house turns up no lead, but it does show that she was in Trenton, and not where she said she was, the day the symptoms started. She tells the team she merely got confused about the dates and it was not an intentional error. She also tells them she broke her ribs back in college when she crashed while cycling.

A short time later, Margaret develops supraventricular tachycardia (an abnormally fast heart rate originating in the top half of the heart). None of the usual tricks (carotid massage, adenosine) work, so she is placed on a pacemaker. Meanwhile, the team calls around for her old medical records, but nothing turns up. Benedict takes it a step further and learns that Margaret didn’t exist until three years ago and she is using the social security number of an elderly lady. When confronted, Margaret tells the team (and her husband) that she was married before and was an abused wife. Her ex-husband beat her and gave her the broken ribs. She moved out, but he found where she was living and poisoned her dog, so she finally got a new identity and moved away. She tells them that her real name is Jenny and that she goes to Trenton for a support group for abused spouses.

Focusing on the heart and stomach symptoms, Benedict is pimped for more possible diagnoses by House and Foreman. Her suggestions of gastritis, atrial fibrillation, cystitis (bladder infection), and cholecystitis (gallbladder disease) are quickly discredited and even mocked (as they should be; those are horrible suggestions). House suggests that Jenny may have been poisoned by her ex, since he did it before and the front door was open. She is started on pralidoxime, an antidote for organophosphate (pesticide) poisoning. The treatment doesn’t work, and she develops a fever (”pyrexia”) of 103. She is placed under a cooling blanket. Endocarditis is suggested and discarded before the team elects to treat possible Legionnaire’s disease.

Jenny’s husband mentions that he called the hospital in Trenton and there is no support group for abuse victims. He wonders what else she may have been lying about. When he tries to talk to her, she starts to hallucinate — mostly worms, snakes, and fire — and starts screaming. Radiology of the brain is obtained and shows a possible lesion. The team believes this to be the cause of her hallucinations and their differential diagnosis is abscess, lymphoma, or Wegener’s disease. Dr. Benedict disagrees and thinks the brain lesion is just a coincidence; she believes Jenny is actually suffering from a mental illness — she suspects bipolar disease. The physical symptoms are from some other, yet to be diagnosed, condition. House disagrees, and has the team prep Jenny ready for a brain biopsy. Just as Chase is starting to drill into the skull, Taub points out that Jenny is no longer febrile — one of her symptoms has stopped. Questioning Dr. Benedict closely, it turns out that she had been slowly turning down the cooling blanket, so Jenny has actually been afebrile (no fever) for some time. Could the fever have just been an antibiotic reaction? (Quick answer: no, Jenny was started on antibiotics after the fever. In fact, that’s the symptom that prompted their use). At this point, it finally dawns on the team that she has not vomited since her arrival. That’s another symptom resolved. House stops her pacemaker and nothing happens — her heart rate remains normal. That was her last major physical symptom, resolved as well. Benedict suggests that Jenny’s mental symptoms — the hallucinations — may have just been caused by a stress reaction to her physical symptoms, but House realizes it is just the opposite. Her mental symptoms were primary, and the physical symptoms are all secondary. He starts her on haloperidol (Haldol, an antipsychotic) and lorazepam (Ativan, an anti-anxiety agent) and tells the team to call him when she wakes up from anesthesia. It turns out that Jenny is a long time schizophrenic. She had been secretly seeing a psychiatrist in Trenton (hence her frequent visits) and had been taking risperidone to control the schizophrenia. Unfortunately, she started to develop side effects (abdominal pain, initially) to the medication so her doctor started to wean her off the medication -– which was then stopped abruptly when she was admitted to the hospital. Her physical symptoms were all risperidone induced and her hallucinations were the schizophrenia returning.

As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

So Jenny’s side effects from the risperidol worsened when the medication was stopped? She didn’t develop the fever and tachycardia until she had been off the medication for some time.

Vagal maneuvers are first line for SVT (i.e. do them before injecting adenosine). When those don’t work, then you try adenosine, several doses if needed. If that doesn’t work, then you go for cardioversion (i.e shock). Pacemakers have no role in the treatment of acute SVT.

Sorry to correct the psychiatrist, Jenny was suffering from hallucinations more than delusions.

And she has an unexplained lesion in her temporal lobe.

Angiogrophy is not the primary test for diagnosing hepatic fibrosis. It can be helpful in looking at the extent of the disease once it has been diagnosis, but it’s not very good at diagnosis. (Ultrasound, CT, or MRI are better choices, but a liver biopsy is really the gold standard for diagnosing hepatic fibrosis).

Maybe Jenny hadn’t vomited because, like most patients with nausea and vomiting, she was on strong anti-nausea medications.

While pralidoxime is used for the treatment of organophosphate poisoning, atropine is also required (in fact, recent studies suggest atropine is the key component and pralidoxime not so important).

An EKG and lack of Osler’s nodes are not good reasons for ruling out endocarditis (Osler nodes, for instance, only occur in 10-25% of endocarditis patients). Echocardiogram is better, but even at best it’s only about 90% correct. You need lots of bloodwork, especially blood cultures, to truly rule out endocarditis.

I like how House slams a patient with a major tranquilizer (haloperidol) and a minor tranquilizer (lorazepam) and expects her to wake up (even in a few hours) and be intelligible. Not going to happen.

So the whole “they’re calling from inside the house!” opening was just a red herring and had nothing to do with the diagnosis at all. So she just left the doors open?

And she has an unexplained lesion in her temporal lobe.

This was yet another good medical mystery, even though the symptoms were very common — common enough to make we wonder why she ended up on House’s service. Still, I give it a solid B. The final solution was clever and, if one ignores the timecourse, fits. I give in a B-. The medicine was about average. For the second week, the progression was fairly logical, though points are deducted for some relatively obvious errors (antibiotics/fever, SVT treatment). I give it a B-. The soap opera was still good. I liked the new doctor — even though she clearly wasn’t cut out for House’s team — but need to see more Wilson. I given it a B.

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

Public Service Ads praising the United Nations were very common during the time DC was doing their monthly PSA program. Of course, this was the era when the United Nations and the United States got along splendidly — I don’t think we’d see similar PSAs today due to our more contentious relationship.

This particular PSA plays up the role the United Nations played in getting Indonesia its independence from the Netherlands following World War II.

According to this PSA (published in December 1955), the population of Indonesia is 80 million. Today, 55 years later, the population is 238 million (over 130 million live on the main island of Java).

The part where the PSA glossed over the repeatedly broken ceasefires, reminds me of nothing more than Monty Python and the Holy Grail:

Other United Nations PSAs: Sharing — The United Nations Way, Your United Nations at Work, Children of Tomorrow, and Superman Shows How UNICEF Spells Help for the Children of the World!

This PSA can be found in DC comics from December 1955, with a script by Jack Schiff with art by Win Mortimer.

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Tags: comics psa united nations indonesia jack schiff win mortimer

Dr. Phillip Solar is a nuclear physicist who became exposed to high levels of radiation when someone sabotaged the nuclear reactor he was working on. A fellow researcher died in the accident, but somehow Dr. Solar not only survived, but became living radiation, able to absorb and release all kinds of energy.

On the other hand, when Solar needs to control his radiation — in this case to attend a scientific conference — he would take some Cadmium Pills. I’m assuming cadmium was chosen because it is one of the elements used in nuclear reactor control rods.
(Once again, with no digestion, I guess the pills just sit in his stomach absorbing neutrons).

A solid episode of Fringe, if more workmanlike than imaginative

The Plot: Senator Van Horn has just bought some lemonade from a roadside stand when his car his hit by a truck. He is rushed to the hospital, but the doctors are puzzled by what they see: he has no pulse, yet he is still breathing. They are preparing him for surgery when Newton walks in, gun blazing, to steal the body. Broyles happens to be in the hospital visiting with Van Horn’s wife and chases down Newton. After a gun battle lasting the length of the hallway, Newton escapes, but not before deliberately shooting Van Horn in the right eye. A look at the silver blood seeping from the corpse and Broyles realizes that Van Horn was really a shapeshifter.

The Fringe Team is called in to evaluate. Fauxlivia and Peter look into the Senator’s congressional dealings in an attempt to learn what he knew. They discover he was following the activities of Fringe very closely. Meanwhile, Walter and Astrid work on the Senator’s corpse. Initially, Walter is able to achieve some mild hand and eye twitching, letting him know that Van Horn is not completely dead, but eventually he is able to provoke some more definite neural responses. He believes he can use these provoked responses to discover where the shapeshifter’s memory center is, and hopefully, harness its memories. To achieve this, the Senator’s wife is brought in. When she speaks to the shapeshifter, the neural impulses localize to the base of the spine. The corpse then sits up and starts spouting numbers and names that the Senator’s wife recognizes as references to their upcoming anniversary. Discouraged, Walter suspects the shapeshifter’s memory must be corrupted. However, later, when going through the cafeteria line and musing on animal (and dinosaur) crackers, he has a flash of inspiration: the shapeshifters have a “second brain” at the base of their spine, just like a stegosaurus. He hustles up to the lab to find this accessory brain. Unfortunately, this is the moment when another shapeshifter sent by Newton arrives. He knocks Walter out and takes the accessory brain for himself.

Peter, Fauxlivia, and Astrid arrive a moment later. When they discover Walter is not seriously injured, Peter is able to use the security cameras to learn the identity (well, assumed identity) of the second shapeshifter. He and Fauxlivia arrive at the shapeshifter’s house just in time to see Newton throw his dead body in the trunk of his car. A car chase follows (pausing just long enough so we get a close up of the brand of car Peter is driving – I’m surprised we weren’t treated to a Sync call in the middle of the chase) and ends when Newton crashes his car in the middle of a tunnel. Fauxlivia reaches him first and retrieves the secondary brain before arresting him. Later, Fauxlivia visits Newton in prison and slips him some poison. He taunts as she leaves, some time later he finally takes the poison and dies a painful death – just as Fauxlivia is seducing Peter back at her apartment.

1. We Can Build You
The title of this episode is a clear reference to Philip K. Dick’s novel: Do Androids Dream of Electric Sheep?, probably best known as the source of the movie Blade Runner. Though the book and movie both cover the same basic story of “retiring” human-looking androids, they approach it very differently. The movie, though it has its thoughtful moments, is more of an action thriller, while the book takes a psychological approach through and through. With at least two of the shapeshifters leading apparently normal human lives, and Ray at least aspires to nothing more than that, I think the book’s approach is a closer fit for the episode. If you haven’t seen the movie or read the book, both are well worth your time (as an aside, I know many people people prefer the the Director’s Cut of Blade Runner, but I actually like the noir-ish voice-overs in the original film.)
In the dystopian future of the book, owning a living animal as a pet (a sheep, in Deckard’s case) is quite a status symbol. Thus the title Do Androids Dream of Electric Sheep? comes into play (and makes more sense when you look at it this way). Similarly, is the shapeshifter Ray aspiring to a “sheep”? Was the Senator?

2. I’ve Never Seen a Trauma So Clean
The trauma of that severe a car wreck didn’t cause any external bleeding in the senator? Nothing to show his mercury-like blood?

3. Shocking
EMT: “No pulse? Charge v-fib?”
I’m assuming she means to charge the defibrillator to the ventricular fibrillation settings. This may or may not be appropriate, depending on what rhythm Van Horn is in, from pulseless v-fib (go ahead and shock) to asystole (flatline, do not shock), or something in between. They need to know the rhythm before deciding whether or not to shock him. If only they were in some facility that had some way of detecting and recording the pulse! (Actually, the defibrillator almost certainly has a rhythm monitor on it, they all do now).

4. Important, or Not?
If the secondary brain was so important, why didn’t Newton shoot van Horn there as well? Something that size would certainly have turned up during an autopsy.
For that matter, after this episode stressed the important information in that secondary brain, why shoot Ray in the head only? Surely the Fringe Team will find Ray’s secondary brain (and what about Newton’s)?
Speaking of Newton, how does him being a shapeshifter jive jibe with his head being frozen in a jar for so long?

5. La Paz
Newton calls her Bolivia too now?

6. In The Dark
A federal detention center like that has no cameras, or keeps no records of who was there? Surely it shouldn’t be hard to discover that Fauxlivia visited Newton a short time before he died.

A solid, if uninspired episode, of Fringe. The title is great though (which, on second thought, means there was at least a little inspiration). The Doomsday Clock stays where it is at 11:54.

This week’s Fringe cipher was: SHIFT.
A list of all previous Fringe reviews is available here.
Karl has much more to say.

For those coming in late, Scott’s First Law of Comic Book Medicine deals with the “shorthand” comic book writers frequently use:
When someone is described as a psychiatrist, that’s shorthand to let the reader know that the character is devious and likely evil (or to simplify even further: “psychiatrist = evil”). For example: pretty damn much every comic book psychiatrist ever. Is there even a non-evil psychiatrist left? Dr. Samson was the last one that I knew of, except that now he’s the evil “Samson.”
When someone is described as a surgeon, that means that they are not only extremely competent but downright brilliant, the best of the best. For example, Dr. Strange, Cardiac, Hush.
If someone is described as a family doctor or general doctor, that means that they are a paragon of compassion and likely still make house calls. The best example is Dr. Bromwell, from various Spider-Man titles.

Scott’s Second Law of Comic Book Medicine: Any hero with a “doctor” in their name or an advanced degree — no matter their actual field of specialty — will eventually be called upon to act as a medical doctor.
Examples:
Dr. Reed Richards (multiple PhDs): Does a great deal of medicine, including delivering babies (on the moon, no less).
Dr. Jericho Drum (Brother Voodoo) (psychologist): Treated his sick brother with injectable antibiotics in his very first appearance.
Dr. Hank McCoy (multple PhDs): For a long-time, the X-Men’s resident physician, despite not actually being a physician. I’ve discussed Henry McCoy many, many times.
Dr. Kimiyo Hoshi (Dr. Light) (astrophysicist): Acted as team physician during her stint in the Justice League, and now in Supergirl.

This week, Jock M had the high score with 15 points, followed by atg with 10 points. Jamie Pt, Matt T, and shadowkate all tied for third with 7 points.

Overall, Gary retains the lead with 28 points. Tippi falls to second with 25 points. Jock M storms into third with 24 points. Fran is fourth with 23 points and Sapramiska drops to fifth with 22 points. If your score is 15 points or higher, you are in the top 10%.

Click here to see the full scoreboard.

While the medical mystery and solution(s) were interesting, the medicine was poor in the week’s episode of House. Trivia-wise, I think this was the first time a patient of the week was portrayed by a relative of a previous patient of the week.

Kayla is an eight-hour old, full-term infant who was hypoxic (low blood oxygen level) when born and required aggressive resuscitation. House’s team is asked to evaluate her for non-specific “breathing problems.” She had been given surfactant (which means that neonatal respiratory distress syndrome should not be an issue). Her sperm-donor father had a history of asthma. House suspects the breathing problems reflect something that is going on elsewhere in the body. Chase reports that her LFTs (liver function tests) are elevated. House now believes that her breathing problem is due to pulmonary edema (fluid leaking into the lungs) because of inadequate protein production in the liver (protein keeps the fluid in the blood vessels, when there’s not enough, fluid leaks into the surrounding tissues like the lungs). He wants a closer look at the liver.

House’s team performs an ultrasound on Kayla’s liver looking for a possible abscess. They see a suspicious area, but it does not appear to be an abscess and is more suspicious for dilated bile ducts. House takes this to mean that the baby has Caroli’s Syndrome, and she is taken to surgery.

Despite their best efforts, the team is not able to perform the surgery because Kayla’s blood pressure keeps dropping. With House busy at Cuddy’s place, the team looks at a differential diagnosis that includes both heart and liver problems. Tuberous sclerosis is suggested, as is a vascular malformation. The latter seems the most likely. Surgery is the preferred treatment, but the team doesn’t want to put her through that again so instead they start her on steroids (probably for inflammation), dopamine (to keep the blood pressure elevated), and an anti-angiogenesis agent (a medication that stops blood vessels from growing). She responds to the treatment, but before the team can congratulate themselves too much, House tells them that a vascular malformation doesn’t fit the case and that Kayla will start having problems soon. Sure enough, she starts bleeding heavily again. Taub mentions hepatic fibrosis, but the symptoms don’t match. Unsure of what else to do, House has the team give Kayla a direct transfusion from her mother, which works wonders.

With Kayla improving after a transfusion of her mother’s blood, the question becomes did the transfusion work because Kayla needed something found in anyone’s blood, or because there was something specific to her mother’s blood that made her better. They hook her up to Taub who has a compatible blood type, but Kayla’s condition takes a turn for the worse. Thus, there was something only found in the mother’s blood that was helping Kayla. Taub tells Kayla’s mother that this means infection. The team gets a sample from the liver, but looking at the nearly black color of the sample tells them that it’s no infection, but a melanoma (a very nasty cancer). Furthermore, they surmise that the melanoma came from the mother in utero. Sure enough, a melanoma is found on mom, but she seems surprisingly healthy for someone with a metastatic cancer. The team surmises that she has some other condition that is preventing the melanoma from spreading — the most likely being some kind of autoimmune condition (scleroderma, dermatomyositis, Churg-Strauss, and lupus are all name checked) or a granulomatous infection (tuberculosis, for example). Autoimmune testing is all negative, so the team moves on to scanning mom for granulomas. They don’t find an infection, but they do find a lung cancer and it seems that the body’s antibody reaction to this cancer is what is keeping the melanoma at bay.

Decision time: the team wants to surgically remove mom’s lung cancer, however this means that her blood will no longer be life-saving to Kayla and the baby will need chemotherapy. Instead, knowing the risks, mom decides to put off surgery until Kayla’s melanoma has been treated by her blood. Unfortunately, as to be expected in a purposefully tear jerking episode, the mother dies of a massive blood clot. Luckily, enough of her blood was saved to finish Kayla’s treatment.

In the side story, House and Wilson suspect Cuddy’s daughter Rachel has swallowed a dime while they were babysitting her. Rather than tell Cuddy what happened, they sneak her into the hospital to ultrasound her and see what looks suspiciously like a coin. They feed her laxatives, but to no avail as no dime emerges. Just when they are ready to perform a colonoscopy, new information comes to light suggesting that Rachel did not actually swallow a dime. House is greatly relieved until later that night when Cuddy changes Rachel’s diaper and finds a dime. Rachel blames House.

There have been multiple cases of melanoma passed from mother to child. However, I could find no mention of antibodies is patients with small-cell lung cancer protecting against other cancers, but my search was admittedly brief, and I suspect there is probably a case study out there somewhere – there is usually some real world basis for House story lines.

As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

Those miraculous antibodies that kept Mom safe from melanoma and cured Kayla through transfusions of mom’s blood are the same antibodies that would have passed to Kayla through the placenta and would have protected her/treated her just as easily in utero. (And I don’t buy the “melanoma was just caught in the crossfire” lame explanation House gives to try and gloss this over. If the antibodies are good enough to keep the melanoma from spreading in mom, they’re good enough to protect the baby as well.)

8 to 9 days to eradicate a cancer is incredibly optimistic and based on way too few data points to be credible. After all, Mom had the melanoma and the antibodies for over nine days and her cancer wasn’t eradicated.

Though Mom died, I would have made the same decision. Seriously, she’s had the cancer for weeks — if not months — at this point, what are a few more days?
And Let’s not forget that immobilization following surgery is another risk factor for blood clots.
Bear in mind that fetal melanoma when obtained from mom is “almost invariably fatal.” If you have a treatment that works, stick with it.

The fact that Taub is a Type-O “universal donor” doesn’t matter here. Type O- is only the universal donor when just red blood cells are given (which, admittedly, is how most transfusions are normally given nowadays). However this was a whole blood transfusion, and when whole blood is given, the antibody-containing plasma is transfused as well. For plasma transfusions, the roles are switched and O- is more likely to have antibodies that cause transfusions reactions than any other blood types. Since whole blood transfusions contain both red blood cells and plasma, they require identical blood types.

Once the dime has made it past the ileocecal valve (which is what the ultrasound showed), you’re home free. That means it’s past all the tight spots and only the large intestine remains. If anything, the ultrasound was good news, not bad news.

Even if coins were magnetic, there’s no way a refrigerator magnet would work. Those magnets are so weak their magnetic field doesn’t even make it through the skin (which is yet another reason all those magnetic bracelets and wraps and shoes are bunk – they use the same weak magnets).

Taub’s statement that “it must be infection” after his transfusion didn’t work was quite a jump. What other signs of infection did Kayla have? Fever? High white count??

Wonder why they didn’t mention herpes as a potential protection/treatment against cancer since they had an entire episode based on that.

It was another interesting medical mystery this week; except for the first episode, they’ve been pretty good this season. It earns a B. The final solution of prenatally acquired melanoma was clever, but the protective antibodies against another cancer was stretching it — still, I give it a B-. The medicine was below average. There was no logic behind most diagnostic choices, and House’s random and unsupported decision to transfuse the baby with mom’s blood was out of character. It deserves no better than a weak C-. The soap opera was still good. The Wilson/House interplay was good, and I also liked Dr. Cheng’s dressing down of Taub at the end. I give it a B+.

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

Valkyrie #1 “Tragic Opera”
Brian J.L. Glass, writer
Phil Winslade, penciler

In the first scene, Valerie falls from a hotel balcony several stories high. When we next see her, a pair of paramedics is trying to revive her. Ziggy is performing CPR but getting no response, so he asks his partner for the paddles.

I would have asked for the defibrillator sooner. Not to administer a shock, but to use it to check out the heart rhythm. That would tell the EMTs right away whether there is pulseless-yet-shockable rhythm (in which case, shock right away! The longer you wait, the lower the chance of success), or a flatline. The story suggests the latter: that Valerie’s heart has stopped and she is all but dead. In that case, asking for the paddles is wrong because you don’t shock a flatline.

Frankly, that the heart has stopped is not Valerie’s primary problem. She didn’t just collapse from a sudden heart arrhythmia — no, she has just fallen several stories and sustained major injuries. It’s likely the heart stopped because it sustained severe blunt force trauma, in which case no amount of CPR or shocking is going to get it going again. It’s also possible that the heart stopped because of other injuries she sustained: she may have suffered massive blood loss (a broken femur or two, for instance), a tension pneumothorax, or cardiac tamponade, for example. In this case, it will be impossible to restore a healthy heart rhythm unless the underlying problem is corrected. Trying to shock Valerie’s heart is pointless because 1) it won’t work, and 2) that’s not really her main problem. (I will acknowledge that this scene sets up the subsequent heavenly thunderbolt revival, but while an Asgardian lightning bolt might restore life, a defibrillator won’t).

Other thoughts:
Ziggy also needs to work on his paddle placement. Shocking the breasts is not the preferred technique — especially since Valerie seems to be wearing an underwire bra. Mythbusters looked at the underwire/defibrillator myth and decided that it’s entirely plausible that burns may result, especially when the paddles are positioned incorrectly like this.

Ziggy should work on his CPR technique: the arms need to be straight to deliver the necessary force to compress the rib cage and heart. I know television and movies show CPR with bent elbows, but that’s so the actors who are playing the victim aren’t injured. This is comic — there are no actors to injure: Ziggy needs straight arms.

If I had known, I would have baked a cake.

scene from X-Force #102. Art by Portacio, story by Ellis and Edginton

Mad scientist Niles Roman has invented a process to cause people who are “latent” mutants into fully-powered mutants. Unfortunately, the process does have its drawback, such as the nosebleed seen here (plus the slight problem that the victim become violently psychotic)

All previous Psychic Nosebleed Zen posts.

Tags: comics medicine nosebleed x-force mutant

I’ve talked in the past about how difficult it must be for a doctor in a world of super-heroes. How can you tell if a patient has a classic migraine headache or are a victim of a psychic attack? Or maybe their mutant powers are starting to emerge?

Comic books are also filled with strange and deadly diseases which doctors would need to be able to recognize. Here is a simple quiz which I’ve limited to only comic book diseases with the word “Plague” in their names. How many can you identify — and maybe more importantly — how many can you successfully cure?

Further information (for you masochists in the audience): The Fever Plague, the Green Plague, the Purple Plague, the Seeing Plague, and the Yellow Plague.

In 1971, concerned about increasing illegal drug use, the Department of Health, Education, and Welfare asked Stan Lee to write an anti-drug message into one of his comics. He agreed and wrote a three-part tale dealing with drug abuse that spanned Amazing Spider-Man #96, 97, and 98. Unfortunately, when he submitted the comics to the Comics Code Authority, they were turned down because of the story’s depiction of drug use. Never mind that the theme was clearly anti-drug, and never mind that the government itself had requested the story — the comics were denied for Comics Code approval. Lee decided that the stories needed to be told regardless, and decided to go ahead and release the comics without the Comics Code seal.

Amazing Spider-Man #96-98
Peter Parker has just returned to New York City from an ill-fated trip to Europe to see Gwen Stacey. Swinging around as Spider-Man to clear his mind, he rescues a man so high on drugs that he tries to fly off a tall building – with predictable results.

Now Peter hits us over the head with the theme of the storyline, just to make sure we don’t miss it.

Meanwhile, Mary Jane has her first show and Harry Osborne is annoyed that she seems to be paying more attention to Peter than to him. He takes a handful of pills to help him relax.

As if things weren’t hectic enough, Norman Osborne becomes the Green Goblin again and hunts down Peter Parker, knowing he is really Spider-Man. As the story progresses, Spider-Man and the Goblin repeatedly clash while Harry’s illicit drug use worsens. In the end, Harry ends up hospitalized for a drug overdose, and the sight of his sick son is enough to turn the Green Goblin off his thoughts of revenge.

Notes:
Interestingly enough, at the time this story was published, the Comics Code did not even mention drugs. Most of the code was taken up with severely restricting the horror and crime comic genres. The next section dealt with advertising and romance comics (no sex, divorce, or -gasp- liberated women). For everything else, there was a catch-all phrase “All elements or techniques not specifically mentioned herein, but which are contrary to the spirit and intent of the code, and are considered violations of good taste or decency, shall be prohibited” and this is what allowed them to go after drug use in comics.
Shortly after these comics were published, the Comics Code was revised, and drug use could now be shown as long as it was in a decidedly negative light: Narcotics or Drug addiction shall not be presented except as a vicious habit. Narcotics or Drug addiction or the illicit traffic in addiction-producing narcotics or drugs shall not be shown or described if the presentation:
(a) Tends in any manner to encourage, stimulate or justify the use of such narcotics or drugs; or
(b) Stresses, visually, by text or dialogue, their temporary attractive effects; or
(c) Suggests that the narcotics or drug habit can be quickly or easily broken; or
(d) Shows or describes details of narcotics or drug procurement, or the implements or devices used in taking narcotics or drugs, or the taking of narcotics or drugs in any manner; or
(e) Emphasize the profits of the narcotics or drug traffic; or
(f) Involves children who are shown knowingly to use or traffic in narcotics or drugs; or
(g) Shows or implies a casual attitude toward the taking of narcotics or drugs; or
(h) Emphasizes the taking of narcotics or drugs throughout, or in a major part, of the story, and leaves the denouement to the final panels.

This was not the first code-era comic to mention drug use, but it is undoubtedly the most famous (and was much more explicit than the previous story). According to Brian Cronin’s always excellent Comic Book Legends Revealed series, Strange Adventures #205 was likely the first comic to mention drugs.

The exact drugs depicted in never mentioned. Clearly, the first victim was using a hallucinogen of some sort. Harry seems to be taking both uppers and downers.
According to my handy dandy The Amazing Spider-Man: Official Index to the Marvel Universe book, Amazing Spider-Man #121 and #122 explained that Harry was taking LSD. This really doesn’t fit. The depiction was clear: Harry was taking meds that relaxed him (downers) and excited him (uppers). There were no hallucinogens involved. Some of the drugs he abused were prescription drugs from his medicine cabinet — which couldn’t be LSD, but could be either of the others.
Stan Lee explained in an interview that he knew nothing about drugs, so kept the story vague on purpose.

And now some gratuitous J. Jonah Jameson:

More PSAs

Tags: comics psa spider-man stan lee drugs comics code

scene from The Adventures of Superman #562

No, he’s not a caricature at all, is he? Not only does he have a head mirror (worn almost correctly, if only it were facing the other way), but a saw and a bloody butcher’s apron as well. I guess it is almost Halloween.