Polite Dissent

This was a Fringe episode left over from Season One that had never been aired — and it wasn’t a particularly good episode, but better than some that were aired. There was at least one good plot twist.

The Plot: Lisa, a seventeen year old high school junior has been declared brain dead after a cerebral aneurysm. Her life support is shut off and she is declared officially dead before being wheeled into the operating room to harvest her organs for transplant. Once the operation has started, she suddenly sits up, alive, and screams out a series of code numbers. It turns out the code refers to a naval officer by the name of Andrew Rusk — and he has been reported missing. The Fringe team is called in to investigate.

Lisa denies ever having met Rusk, but when his name is mentioned, she speaks a phrase in Russian which translates to “my (or ‘little’) star.” Lisa has developed a fever and the doctors are watching her closely. Her mother tells Agent Dunham that she doesn’t want the team questioning Lisa anymore when Lisa suddenly screams from the bathroom — when looking in the mirror she has seen the image of Rusk standing behind her. Walter hypothesizes that Lisa’s aneurysm affected Broca’s area, a part of the brain which controls language — and according to Walter — also controls psychic ability.

A little while later, Lisa calls Agent Dunham, telling her that she still is still seeing Rusk. She is at a junkyard, because she saw the image of it in her mind. When the Fringe team finds her, she tells them that Rusk was shot there. Sure enough, a 9mm casing is found and a short time later, Rusk’s body is found. Lisa has a sudden seizure and is readmitted to the hospital.

Walter deduces that Rusk’s death and Lisa’s rebirth occurred simultaneously, and somehow this allowed her to pick up his memories. Lisa’s mother allows Lisa to be taken to Walter’s lab to purge the memories.

Meanwhile, Dunham finds out that Rusk used to call his wife the Russian phrase “my star.” She also finds out that he was exposed to high radiation doses in a shipboard accident and was given an experimental radiation inhibitor.

Back at the lab, Walter hooks Lisa up to an EEG, pumps her full of drugs, and the team discovers that she doesn’t just have some of Rusk’s memories — his entire consciousness is sharing her brain. Rusk’s personality emerges when the drugs put Lisa to sleep. He is able to give the team enough of a lead to track down his killer — a former Navy SEAL. When the suspect is questioned by the FBI he admits that he killed Rusk, but he did it because Rusk was a wife beater — Rusk’s wife hired him to kill her husband. He tells the team that he mentioned this fact to Rusk before shooting him.

Rusk is still in control of Lisa’s body, but by pretending to be Lisa, manages to sneak out of the lab. He goes to his house and grabs his gun. He confronts his wife, but she denies having anything to do with his murder. He ties her up and is getting ready to start a house fire when Peter arrives, with the rest of the team following a short time later. Peter talks to Lisa/Rusk enough to distract him so that Charlie can shoot him with a tranquilizer dart. Further testing in the lab reveals that only Lisa’s consciousness remains within her mind.

1. Breathe, Breathe In The Air. Since Lisa stopped breathing and died once the ventilator was stopped, why are they bagging her on the way to OR? (And if you want to argue that they are bagging her to provide oxygenated blood to her organs, then they also need to 1) give CPR, and 2) continue to bag her in the OR).

2. Infection Control, What’s That?
Lisa has enough of a fever to worry her doctor, but is discharged the next day — and immediately returns to school and church? Where lots of sick people are? (Assuming she goes to church on Sunday, it seems impossible for her to have made it back to school. By my calculation she would have been discharged late Friday at the earliest.).

3. Total Nit-Pick About Balloons
Hospitals are picky about which balloons are allowed. The ones is Lisa’s room are not allowed due to concerns about latex allergy.

4. I Wish All Surgeries Were That Easy
Abdominal surgeries, even on dead people, are not that easy. The renal artery is way in the back and all the intestines have to be moved out of the way before it can be reached.

5. Seize Her
That was one of the more unconvincing seizures I’ve ever seen.
Speaking of seizures, while I agree with the hospital doctor that in most cases the cause of seizures are never identified, I would not so cavalierly dismiss the idea that it was related to her aneurysm. She had a recent bleed in her brain, and blood is a very irritating substance — not to mention the swelling from the injury — which is enough to set off a seizure.

6. Too Many To Choose From
It was nice of Walter to put her on 100 mikes (micrograms) of a benzodiazepine, but it would help if he told Astrid which one to use. He typically has used Valium, but the doses he is giving fits Versed better.

7. Too Late To Matter
With a dose of 600-1000 REM, Rusk would have had the initial symptoms of radiation poisoning starting shortly after exposure (mostly nasty gastrointestinal ones). His bone marrow would be dead and he would require a bone marrow transplant to have any chance of survival (and for the record, only one person has ever survived that dose of radiation).
Once Rusk was removed from the reactor, he was no longer exposed to the radiation — and since he is not radioactive himself (radiation doesn’t work that way) — giving a radiation inhibitor at this point is useless, like closing the barn door after the horse has left. There is no radiation left to inhibit. The damage has already been done.

8. Quickdraw McGraw
Intramuscular medications (like the tranquilizer dart) do not take immediate effect. The medicine must be absorbed into the blood stream and spread throughout the body — or at least reach the brain) before it knocks the victim out.

9. Enough Already, George Michael
Scientifically-based faith (e.g. I have faith the sun will rise tomorrow) is a completely different concept than religious-based faith and the terms are not really interchangeable.

Since this is not a current episode, it’s not going to affect the Doomsday clock — which is a good thing for the show.

Tags: television fringe brain psychic possession

This week’s episode of Fringe was fairly creepy, and the science wasn’t all that bad

The Plot: A boat from Hong Kong has run aground in the harbor and dozens of illegal Chinese immigrants have washed up on the shore, dead. It turns out it wasn’t the water or cold that killed them, but giant tentacled parasite worms lodged in their gastrointestinal tracts. The Fringe team is called in. One of the immigrants, Mai Lin, managed to survive. She tells the team that all her fellow immigrants were given a strange capsule to treat sea-sickness, but since she was raised in a fishing village and never got sea sick, she didn’t take it. The team suspects these capsules contained the larvae for the giant worms. She tearfully tells the team that her husband and daughter are on the next boat arriving in few days.

The immigrant smugglers are tied to a local Triad gang best known for smuggling and selling illegal drugs. The team initially surmises that the worms secrete some form of opiate, and this is why they’re being smuggled. After being bitten himself, Walter realizes that the worms produce a powerful immune boosting agent. Walter does some research and discovers that the worms are genetically modified Ancylostoma duodenale (hookworm), an intestinal parasite used in traditional Chinese medicine. The genetically modified versions make an immune boosting agent that is stored in their lymph glands.

Some financial documents tie a local woman to the one of the Triad’s front. She tells Agent Dunham that she has no knowledge of any illegal activity and only invested the money where her financial adviser suggested. Peter notices that her house has a surprising number of air filters and hermetically-sealed windows. Once the team learns about the immune-boosting aspect of the worm, they realize this woman knows more than she is telling. This time, Peter approaches her son who tells him that he has a rare immune deficiency. He receives a special monthly treatment of worm-powder delivered surgically, directly into his spleen.

Walter, with some reluctant help from Astrid, heads off to Chinatown to find a herbalist that sells Ancylostoma that is genetically similar to the giant worm. He finds several shops that sell the worms, and inadvertently discloses to one of the shop owners — the wrong one, of course — that he has a giant worm back at the lab. The Triad follow Astrid back to the lab, beat her up, and steal the parasite.

The ship carrying Mai Lin’s family is found and boarded, but it is too late — all the immigrants have already been carted off. Luckily, Peter is spying on the shop in Chinatown where they have been taken. He calls Agent Dunham then decides to do some investigating of his own. He breaks in to the shop and is in the process of freeing one of the immigrants when he is captured. The Triad and their crooked doctor are force feeding Peter one of the larva when the FBI team arrives, just in the nick of time. The villains are shot or captured, Peter is saved, the immigrants are taken to the hospital where they are treated, and everything ends happily.

(Oh, and Walter implanted a tracking chip in his neck.)

Overall, the science — what little there was of it — was passable this episode, so I just have a few nit-picks an observations:

1. As the Worm Turns
Nematodes such as Ancylostoma are too primitive an organism to have a lymphatic system. They don’t even have a circulatory system.
Admittedly, these are “genetically engineered” hookworms, and for a worm to grow as large as those shown, thanks to the square-cube law and other similar concepts, they would have to have some sort of circulatory system.
In the actual worms, the many-tentacled end is the tail, not the head.

2. Glad I Don’t Have to Take Them Out
Matt’s staples should have been removed long ago. He was 3 ½ weeks out from his surgery. By this far out, the incision is healed with 80-90% strength. Leaving in staples or stitches that long serves no purpose, is going to lead to train-track scarring, possible stitch abscesses, and skin-growth around the staples.
Open abdominal surgery is to be avoided whenever possible, especially in immune compromised individuals. Why not just inject the powder into the spleen?
Credit-Where-Credit-Is-Due Dept: That is where an incision for splenic surgery would be made.

3. High is Not Always Better
A high white blood count is a sign of infection (or leukemia, not the sign of a healthy immune system).

4. Ahhh, Just Right
I was starting to have concerns with Walter’s mention of “boosting the immune system” — a common alternative medicine/quackery claim. In reality, the human immune system is finely tuned: too little leaves you open for infection; too much and you get allergy problems and autoimmune disease. If all the alternative “medicine” boosted the immune system like it was claimed, we’d have an epidemic of autoimmune problems in this country. I’ll give the episode credit for having the medication be used by immune-compromised patients — a proper use.

5. What Does the FBI Teach These People?
Walter’s about as good an investigator as Olivia — that is, very bad. The logic of his whole “find a matching worm” plan had more holes than Swiss cheese (though this is Walter we’re talking about). For instance, who’s to say the various different herbalist shops didn’t all use the same importer of worms — which they probably did — so the worms from the various shops would be identical.
And Peter’s not any better. Why would he think breaking into a shop owned by the Triad — known for their brutality — would be a good idea at all?

5. Lions and Tigers and Bears, Oh My!
The song Walter was singing was “The Menagerie“, which was also mentioned in the first season (episode 16, Unleashed).

While there was some errors of scientific-concerned, most of them were minor and could be hand-waved area. Thus, for the second week in a row, there is a one-minute improvement on the Doomsday Clock.

Tags: television fringe parasite ancylostoma worm

In this public service ad, Binky’s younger Allergy and his friends ponder the future — the far, far distant future — of 1976.

Click on the image for the full ad

This PSA is found in DC comics from June 1956. The writer, as always, was Jack Schiff. Art by Win Mortimer.

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Tags: comics psa binky allergy jack schiff win mortimer

The mystery was fairly bland in this week’s episode of House, but the medicine was much better overall. Good bye Cameron. Don’t let the door hit you on the way out.

Hank, a successful porn star is admitted to Princeton Plainsboro Teaching Hospital after developing a severe headache and photophobia (sensitivity to light) while on set. House starts off by ordering a series of tests: an STD panel (to look for sexually transmitted diseases), a toxin screen (to look for common toxins), C-Reactive Protein (”CRP”, a measure of inflammation), ANA (antinuclear antibodies, to look for autoimmune diseases) and a lumbar puncture (to look for viral encephalitis). While the patient is having his spinal tap performed, he develops severe muscle spam and pain (tetany) in his arms. Foreman orders meperidine (Demerol, a strong pain medication).

About this time, House starts hitting up Taub and Thirteen for ideas, trying to lure them back on the team. Taub suggests that Hank must have a brain problem, such as a tumor or seizure. Foreman believes that Hank suffers from cerebral vasculitis (inflammation of the blood vessels in the brain). House agrees with Foreman’s assessment and starts the patient on steroids. He also orders a brain angiogram (an x-ray of the arteries in the brain), as well as an EEG and a nerve biopsy, just to be sure. Foreman convinces Chase to perform the angiogram, but he and Cameron suspect that the patient is suffering from Vitamin D deficiency, so instead of checking the angiogram, they decide to start Hank on light therapy and intravenous vitamin replacement. Unfortunately, while undergoing the light therapy, Hank develops a nosebleed and is found to have petechiae on his legs.

Hank is now diagnosed with disseminated intravascular coagulation (DIC, a weird, but very serious, condition, where the patient is both bleeding too much and clotting too much). Sepsis is suggested as a possible cause, but since he is showing none of the shock associated with sepsis, the idea is discarded. Bacteremia (bacteria in the blood) is suggested, but Cameron shoots it down suggesting instead Meningococcemia (meningococcal bacteria in the blood — really a subset of what Chase suggested). House concurs with Cameron’s diagnosis and Hank is started on heparin (a blood thinner, for the clots) and a broad spectrum antibiotic that covers meningococcus (but if you know which bacteria you’re treating, then you don’t need a broad spectrum antibiotic).

Hank does not improve and he starts to run a fever. Taub suggests that he might have an infection hidden away in his sinuses, where the antibiotics have difficulty reaching, so Chase performs sinus surgery to clear out the sinuses. Now Hank begins to complain of severe abdominal pain and Cameron discovers something on the exam (apparent ascites — fluid in the abdomen) that makes her diagnose liver failure. She suggests a Klatskin tumor (cancer of the bile duct), but it doesn’t quite fit the symptoms. Foreman suggests that Hank has sclerosing cholangitis (a disease that damages the bile ducts). House agrees and an ERCP (an endoscopic exam of the bile duct and pancreas) is ordered — surprisingly it shows a mass in the common bile duct that ends up being a large clump of worms. Hank apparently has strongyloides (”whipworm threadworm”), and is given mebendazole to kill the worms.

Once again, Hank’s condition dramatically worsens. He develops severe pulmonary edema (fluid build up in the lungs). Chase thinks it might be a combination of a hematological (blood) problem and cardiomyopathy (a heart problem). Foremen suspects Hank has lymphoma, with peritoneal carcinomatosis (malignant spread of cancer across the abdomen) and paraneoplastic syndrome explaining his symptoms. House sides with Foreman, and Hank is started on chemotherapy. A short time later, Hank’s condition takes another turn for the worse when he starts urinating blood. Next, his blood pressure and heart rate skyrocket, and he starts to bleed from his mouth. He then suffers a cardiac arrest, but the team is able to stabilize him.

The latest labs are back and show that Hank barely has any red blood cells, white blood cells, or platelets. The differential diagnosis now includes hypopituitarism (an underfunctioning pituitary gland), renal cell carcinoma (a type of kidney cancer), or aleukemic leukemia (a leukemia that is associated with low white blood counts instead of the normally high counts found in leukemia). House tells the team that the latter is the most likely and orders them to ablate (destroy) Hank’s bone marrow in anticipation of a bone marrow transplant. There is a lot of hemming and hawing about whether this is the right thing to do, since it could make Hank sicker or kill him, but at the last moment, Thirteen and Taub call in with the correct diagnosis: extraintestinal Crohn’s disease. According to them, Hank’s exceptionally clean childhood made him more likely to develop diseases such as Crohn’s, and the worms were actually helping him keep the disease in check. Once the worms were killed off, the Crohn’s flared up with a vengeance. With some methylprednisolone (steroids), Hank should get better — but the team wants to give him some worms again, just to make sure.

I found no massive errors in tonight’s episode. There was the usual: jumping randomly between unrelated diagnoses, bizarre test interpretation, and Chase being a specialist surgeon, but nothing horrible. Of course, that’s not to say I have no complaints (as if!). As usual, minor complaints are in blue, nit-picking ones in green:

Where exactly was the extraintestinal focus of the Crohn’s?

Why did he develop a headache and photophobia in the beginning? Was that the Crohn’s? Why did everything suddenly worsen when he got in the hospital? The steroids he was given for the vasculitis should have calmed down the Crohn’s.

The strongyloides worms may not have been the cause of his disease, but their blockage of the bile duct would still cause serious problems for the patient.

Again, no oncologist is going to start chemotherapy for cancer without a tissue diagnosis.

Special precautions are taken for patients who are neutropenic (dangerously low in white blood cells, and thus more susceptible to infection) including gowning and gloving everybody in contact with the patient. You do not roll them down the hospital’s common hallway without a mask and with the wife holding his hand.

The CRP should have been significantly elevated with the Crohn’s disease (and the cerebral vasculitis too).

While the ANA is generally strongly positive for certain types of autoimmune diseases, it is not found in every autoimmune condition (or even most autoimmune conditions), so a negative ANA does not mean there is no autoimmune disease (and positive ANAs in the absence of autoimmune pathology are also possible).

How about checking the vitamin D level — an easy thing to do — before treating the patient.

I noticed how they avoided actually saying the word “ascites” and instead chose a wordier explanation. Probably because of their problem pronouncing it last time.

Cameron shoots down Chase’s idea of bacteremia, but then suggests meningococcemia, a type of bacteremia. The same argument she used against Chase would go against her as well.

Why would you ablate the bone marrow without finding a donor first? (OK, maybe House was never planning on really following through with it, but why would the others go along?)

And now credit where credit is due:
The hygiene hypothesis is a legitimate and controversial scientific theory concerning the rise in asthma and allergy rates in industrialized nations. Some researchers link it to autoimmune diseases as well.
Helminthic therapy — treatment of disease using intentional infestation of parasitic worms — is being tested in a variety of diseases, including Crohn’s/
Shocking ventricular tachycardia, like Foreman did this episode, is the right treatment.

The mystery was okay, but seemed to get lost in the shuffle as the show progressed. I give it a B. The final solution was a stretch, especially when you look back at the original symptoms. It earns a C. Overall, the medicine was better that it has been the past few weeks and earns another B. The soap opera was decent as well. I enjoy Tab and Thirteen, so I’m fine with having them back, though I know many will disagree. The soap opera earns still another B.

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

The House Challenge scores are now up to date here.

I swear, I have this same conversation with at least two or three patients a day. When will the horror of water allergy end?

This episode of House started well but collapsed under the weight of its ridiculous medicine in a surprisingly short period of time. The soap opera was well done and enjoyable, though

Jordan, a sixteen year-old girl, and her best friend bluff their way into a band’s post-concert party. The next morning when they are regaling their other friends with the details of the night (including alcohol, marijuana, and skinny dipping), her friends notice that Jordan’s ankles are very swollen. Seconds later, her fingers become swollen too, and then she collapses on the floor.

Admitted to Princeton-Plainsboro, House is convinced that Jordan has rhabdomyolysis (muscle damage, often caused by a crush injury. He thinks she injured herself climbing the fence to the pool to go skinny dipping). The rest of the team suggests that she may have a deep vein thrombosis (a blood clot), anaphylaxis (a life-threatening allergic reaction), or even a heart condition, but House maintains that Jordan must have rhabdomyolysis. Tests reveal that Jordan’s muscle enzymes are elevated (a sign of rhabdomyolysis), but the scans show no sign of the muscle injury House was suspecting.

House now looks over the labs and notices that Jordan has a low potassium. He has her air drum (like air guitar, only drumming), but she can only drum for a minute or two before her arms are too tired to lift. House states that this muscle weakness is a sign of low potassium, and since she would have had a low potassium the previous night as well, there was no way she had the muscle strength to climb the pool fence. In other words, he accused her of lying about what happened. Later, Jordan and her friend admit to Cameron and Chase that in reality, they only wanted to go to the party because their favorite comic book/movie writer Jeffrey Keener would be there. They then proceeded to stalk him for the next few hours (going where he went, eating what he ate, etc), before finally going to bed.

The differential now consists of an unknown food allergy, plus Cameron thinks that Jordan may be bulimic. They run a scan to look for a Mallory-Weiss tear (a rip in the esophagus seen in people who vomit frequently, like bulimics), and when they don’t find one, decide that she isn’t bulimic. As they finish the test, Jordan’s blood pressure drops suddenly and then she flatlines. Foreman starts CPR (good for him). Chase announces that Jordan has cardiac tamponade (the pericardial sac — the membrane around the heart — has become filled with so much fluid the heart can no longer beat correctly) and he plunges a needle into her chest to draw off the blood around the heart and relieve the problem. Somehow, this brief moment of tamponade has severely damaged (“constricted”) her heart, necessitating use of antiarrhythmic medications (drugs to prevent abnormal heart rhythms). Since Jordan’s blood pressure drop was sudden, House decides that this means she has an acute problem, not a chronic one. Therefore, the most likely diagnoses are toxin exposure or infection, but the team still needs to figure out which toxin or which infection.

Things continue to worsen for Jordan. She tells the team about stopping by Bruce Springsteen’s house and playing guitar with him . She is lying and does not even realize that she is doing it. Additionally, Foreman notices blood dripping from her ear and announces to her friend that bleeding in her brain is affecting her thalamus and this is causing her to lie. (When did he get an MRI to determine this? And why would bleeding in the thalamus — in the center of the brain — leak out the ear? Did she somehow rupture her eardrum too?)

The team reviews the videotapes from the hotel that night and discover that Jordan sneaked out of her room briefly in the middle of the night. They see her a few minutes later carrying Keener’s journal. He apparently left it in the restaurant and she went back to get it. They figure that she must have stopped by his room to return the journal and maybe something happened to her there. Chase and Cameron confront Keener in his hotel room — he shuts the door in their face. Cameron now suspects that Jordan was slipped some roofies (a slang term for Rohypnol, an alleged common date rape drug) and wants to start her on Flumazenil (a medication which reverses the effects of Rohypnol and similar drugs). When they return to the hospital, they find Foreman frantically working on Jordan. He tells them that she has been bleeding behind her kidneys and has required multiple units of blood. Cameron thinks it looks like a “toxic reaction.”

Cameron realizes that they must figure out what really happened to Jordan that night. Her plan is to give Jordan Amobarbital — i.e.truth serum — so they can discover the truth. Jordan is given the drug, and under questioning, admits that she went to Keener’s room where he invited her in and gave her Ecstasy — only it didn’t have the same effect on her that Ecstasy usually does — this pill made her sleepy. She then begins telling the team how Keener started to touch her. As her father gets more and more upset, Foreman points out that the scans indicate “increased periorbital blood flow” meaning that everything she just said is a lie.

Most of the action now shifts upstate, where Cuddy, House, and Wilson are at a medical conference. At one point, the team talks to Wilson and tells him that since Keener travels with his dog, Jordan may have come down with Rickettsia (not the name of an infection per se, but a genus of tick-borne bacteria that cause such diseases as typhus and rocky mountain spotted fever). A short time later, in the middle of an argument with Wilson, House has his Eureka! moment and calls the team. He announces that Jordan has Vibrio vulnificus, a not uncommon bacterial contaminant of the raw oysters Jordan ate. For most people, the bacteria present no problem (or mild nausea and vomiting), but Jordan also has hemochromatosis. According to House, this made her more susceptible to the contaminated oysters. The Vibrio infection explains her initial symptoms. Then the team, thinking she had bulimia, started her on iron-containing vitamins, which worsened the symptoms of the hemochromatosis (by causing iron overload), resulting in liver damage and bleeding. They gave her transfusions, which again worsened her symptoms (more iron overload). However, with the right diagnosis and some Cetazidime (an antibiotic for the Vibrio) and chelation (for the excess iron), she should be as good as new.

Tonight’s episode was rife with errors, far worse than usual. I did my best, but I’m sure some obvious one slipped by. As usual, major complaints are in red, minor in blue, nit-picking in green:

The truth serum idea was simply ridiculous. Amobarbital does not work like Cameron explained, and it is far from foolproof — for example, it’s easy to create false memories (and the questioner Cameron clearly had a preconceived belief of what happened to Jordan).
Telling truth from lies is not nearly as black and white and Foreman makes it seem. You can’t look at an fMRI report and definitively state “she was lying the entire time” like he did. But it sure would make police interrogations and court a lot easier if it worked as easily as Foreman implies.
Anyway, where is the fMRI? Jordan was in a bed in the center of the room. There was no MRI equipment in sight. Nothing to read the “increased blood flow” he mentions.

Cardiac tamponade or not, you don’t just plunge a needle and syringe blindly into the chest — you’re likely to do more harm than good. Yes, you can perform a needle pericardiocentesis, but it’s more involved than “plunge and pray.”
Why would 20 seconds of tamponade cause a permanent conduction problem in the heart?

A day or two of iron supplementation is not enough to cause that severe liver damage in a patient with hemochromatosis. And apparently it kicked in really fast, because it bled into her pericardial sac mere minutes after suggesting the diagnosis of bulimia, let alone giving her vitamins with iron.

Jordan’s symptoms do not match Vibrio at all. For starters, she has no gastrointestinal symptoms from what is essentially food poisoning.

When did Foreman get an MRI to determine that Jordan had “bleeding into her thalamus?” And why would bleeding in the thalamus — in the center of the brain — leak out the ear? Did she suffer head trauma which disrupted her ear canal and also ruptured her eardrum?)

Rhabdomyolysis can have other causes other that a direct muscle injury, so not seeing a specific injury on the scan means little (for example, many marathon runners end up with some rhabdomyolysis by the end of their race, but it’s not a single muscle, but most of them, so a scan would show nothing)

Not everyone with bulimia develops Mallory-Weiss tears, in fact, most don’t. So not seeing a tear does not mean she is not bulimic.

Edema is swelling of soft tissue. Effusion is the swelling of a joint. They are not the same thing and the terms should not be used interchangeably. A halfway decent physical exam, especially on someone as skinny as Jordan, should easily tell them apart.

Assuming Jordan did receive Rohypnol, the flumazenil, a benzodiazepine antidote, is a reasonable choice. But by the time Cameron would have given the drug to her, the rohypnol would have been long gone from her system.

Rickettsia is a genus of bacteria, not a specific disease.

Rhabdomyolysis is very hard on the kidney. I would think twice, and then a third time, before giving such a person IV contrast (also very hard on the kidneys).

I thought the medical mystery itself, and the confusion of the always changing history, was intriguing this week and deserves a B+. It goes downhill from there. The final solution did not fit the mystery at all — either solution — and earns a D-. The medicine overall was a complete mess, with scattershot diagnoses, ideas abandoned for sloppy reasons, and missing equipment. It earns a solid dismal F. The soap opera was a bright spot — especially all the scenes at the conference — and earns an A.

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A list of all prior House reviews

The House Challenge scores are now up to date here.

With Halloween just around the corner, I thought it was the perfect time for this public service ad featuring Binky and his giant-bowtie-wearing brother Allergy (and yes, he wears his bowtie even in costume).

I’ve mentioned how often these PSAs featured pro-United Nations themes, and this is a perfect example focusing on the United Nation’s Children Fund — better known as UNICEF. This is the third DC PSA featuring UNICEF (one, two), and here’s a bonus Casper PSA thrown in for free.

Click on the image for the full ad

This PSA is found in DC comics from December 1957. Jack Schiff, as usual, wrote this PSA, with Ruben Moreira on art. I scanned this in from a copy of Adventure Comics #243 (which features “The Super-Toys From Krypton,” where Superboy’s childhood toys are sent to Earth. Is there anything Jor-El didn’t send from Krypton — other than more people he could have saved, I mean?) There is also a black and white version that can be found in some comics (Action Comics #235, for instance).

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Tags: comics psa halloween unicef binky allergy jack schiff ruben moreira

It’s once again time to visit with Binky and his strangely-garbed young brother Allergy to learn something important from a public service ad. This week, Binky teaches his younger brother how to make friends.

The advice is nothing new: Talk to new people.

There is something ironic about Allergy not wanting to talk to someone “square” — has he looked in the mirror lately?

Given the usual grasp of slang of Silver Age comic book writers (and I’m looking at you in particular, Bob Haney), I suspect that by the time this PSA was published, kids had long since stopped saying “square.”

Click on the image for the full ad

This PSA is one of DC’s double hits: PSAs that proved popular enough (or deemed important enough) to be published twice. It can be found in DC comics from both July 1957 and July 1965. This particular page was scanned in from Adventure Comics #238. As always, Jack Schiff handled the scripting of this PSA, with Bob Oksner (the artist from the Binky comic) providing the art.

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Tags: comics psa binky allergy friends jack schiff bob oksner

Binky, his brother Allergy, and their dog Sport are back in this public service ad about dental care for both pets and people (though it seems Sports has changed from a black and white coat to a tawny color since last week)

I like the way Sport has his own toothbrush in the bathroom next to everyone else’s — yet still has to eat in a different room than the rest of the family.

Click on the image for the full ad

This PSA is found in DC comics from March 1956. Like last week’s PSA, this ad was written by Jack Schiff with art by Win Mortimer. I found this copy was scanned in Adventure Comics #222.

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Tags: comics psa binky allergy teeth dog jack schiff win mortimer

Because you demanded it, I’m going to end the summer’s public service ads with two weeks of PSAs featuring Binky’s younger brother Allergy, in all his huge bow-tied glory. And not just any Allergy PSAs, but two ads concerning Allergy and his pet dog (though, ironically, allergies to dogs is never mentioned).

This week, Binky and Allergy reveal that they are completely clueless about pets, which makes you wonder why their parents let them have one in the first place. They probably should have started them out with fish, a hamster, or a turtle. For example, based on the sixth panel, I’m wondering if they ever fed the dog before they had that chat with their neighbor. No wonder Sport doesn’t like them!

Click on the image for the full ad

This PSA is found in DC comics from October 1953. Like nearly all DC PSAs, it was written by Jack Schiff. Art was handled by Win Mortimer, who did most of the Binky PSAs. This copy was scanned in from Adventure Comics #193.

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Tags: comics psa binky allergy pets dog jack schiff win mortimer

With summer vacation winding down and families taking a last ditch vacation before school starts up again, I thought a public service ad about camping would be appropriate. This PSA is fairly straightforward: Binky takes his unfortunately named brother Allergy and some of his friends on a camping trip and takes the time to teach them how to do it right.

There is something wonderfully poetic about a boy named Allergy destroying wildflowers.

This is the first PSA I can recall with a typo: I suspect Binky means to say “First Aid” in the final panel and not just “First.”

For a classic vacation PSA, check out How NOT to Enjoy a Vacation! It features a talking dog, what more could you want?

Ever notice how the title to every DC PSA ends in an exclamation point, whether it warrants it or not? It makes me think everyone at DC involved in making the PSAs was always very excited!

Click on the image for the full ad

This PSA is found in the DC comics of May 1955, including Adventure Comics #212, where this was scanned in from. This strip was written by Jack Schiff with art by Win Mortimer.

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General anesthesia is, by and large, an extremely safe procedure that has made modern surgical treatment possible. As with any medical procedure, there are potential risks associated with general anesthesia including allergy, aspiration, and the thankfully rare malignant hyperthermia.

However, there is also another lesser known complication of anesthesia that is routinely overlooked by the medical community: Past-Life Pirate Possession Syndrome.

It all starts with an experimental anesthetic agent:

And goes downhill from there:

There is a cure, but it is difficult, expensive, and requires both a transfusion of megacyclic energy and the assistance of the Spirit of Vengeance. Frankly, preventing the condition in the first place is the easier approach.

So the next time you’re scheduled for surgery, make sure to ask your doctor if they’ve taken the proper precautions against Past-Life Pirate Possession Syndrome.

Scenes from The Spectre #1, by Gardner Fox and Murphy Anderson

While I’ve published more public service ads starring Buzzy, DC’s other teen leading man Binky appeared in his share too. This one is about compromising to make things happy at home.

Seems to me that Mom and Pop screwed up, and are using fancy footwork to cover up their mistakes and suggest it’s the kids’ fault. Way to go Mom and Pop! (Once I would have meant that sarcastically, but now as a parent myself I simply stand in awe of their skillful maneuvering).

Binky’s younger brother Allergy has had the wool pulled over his eyes if he thinks his family constitutes a democracy. Another point to Mom and Pop.

Click on the image for the full ad

This PSA was written by Jack Schiff and had art by Bob Oksner, Binky’s regular artist. I came across it in Action Comics #144, but it can be found in other DC comics from May 1950. It was also reprinted as the January 1954 PSA.

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I thought this would be a good episode of House — the last couple have been pretty good — but I was mistaken. It was surprisingly boring and the medicine was hap-hazard and illogical as well.

Morgan, a thirty-five year-old nursing home nurse comes to see House in the hospital clinic complaining of frequent colds and feeling rundown. As she is asking for some tests to be run, she suffers a tonic-clonic seizure and becomes incontinent of green urine. House decides to admit her.

The team’s initial differential diagnosis consists of infection (especially Pseudomonas) or toxin exposure. House sends Taub and Kutner to search Morgan’s office where they find a bottle of methylthionium chloride (better known as “methylene blue“), a medication that can cause green urine. Taub suspects that she has Munchausen’s Syndrome and has been faking her symptoms. Rather than admit that Taub was right, House sends him off on a fool’s errand.

House now goes to see the Morgan and pretends to induce a photosensitivite seizure. He catches her faking a seizure and she realizes it. She admits that her symptoms were fake, but insists that she is really sick. She knows that she is sick because Debbie the nursing home cat came to sleep beside her. Debbie has a reputation for only sleeping next to people who are dying, so now Morgan is certain that she is at death’s door. House is unimpressed, but then she collapses outside his office, wheezing. Foreman declares that she has bronchospasm, which both House and Foreman agree cannot be faked.

The differential now consists of bronchitis, emphysema, or visceral larva migrans (infection with intestinal worms from the cat). House suspects the latter and has the team perform a bronchoscopy (looking down the lungs with a flexible fiberoptic camera) to find any worms. The test is negative, and so now the team considers acid reflux, allergic asthma, or a panic attack. House thinks the allergy idea is the most likely, so orders a methacholine challenge (a test which provokes asthma is the patient is asthmatic). The challenge test is negative, so Cuddy tells House the he has to discharge Morgan. He takes her out to the smoking area to talk about the dissolution of her marriage and death of her step-son. While there, he notices a rash and she begins to wheeze again. He has another nearby doctor diagnose her with bronchospasm then wheels her back into the hospital. He thinks she has Churg-Strauss Syndrome (a type of vasculitis more common in people with asthma) so starts her on steroids. Morgan now develops brown urine, but there is no evidence of kidney failure, liver failure, an intestinal fistula (an abnormal connection between the intestine and bladder), or blood in the urine. Foreman suggests that the urine only looks brown because it still has traces of green dye and something is making it purple, and purple + green = brown. House thinks this means she may have a Strep bovis infection from colon cancer (about 15% of colon cancers have a concurrent S. bovis infection. The exact relationship between the two is unclear). The team reminds him that her colonoscopy was normal. He orders a pill-cam (capsule endoscopy), which is also negative for cancer.

Kutner suggest that Morgan may have a skin cancer which has spread to her colon. House has him check her over for melanomas. He finds no skin cancers, but does find prominent spider veins on her back which weren’t there before. House now determines that she has Cushing’s Syndrome (Cushing’s is caused by elevated levels of cortisol in the body. This is most commonly caused by high levels of ACTH, a chemical that tells the body to make more cortisol. ACTH-secreting tumors can most commonly be found in the pituitary gland — part of the brain — or the adrenal glands near the kidneys. House is trying to determine which is the source of the ACTH.) An MRI is negative for a tumor in the adrenals or brain, and blood levels of ACTH are equivocal, so House wants Chase to sample the blood from within her brain to see if there are high levels of ACTH there. The surgery is completed, and Morgan is found to have slightly elevated levels of ACTH in her brain. Incidentally, she also suffered a cardiac arrest while in the operating room. House decides that the cause of her Cushing’s Syndrome is an ACTH secreting tumor in the pituitary. The symptoms can be controlled with medication, but surgery can correct the problem permanently. Chase tries to dissuade her from the surgery, but she decides to have it anyway.

About this time, House has his Eureka! moment of the week when the cat comes in to his office and plops down on his laptop. He realizes that Debbie likes warm places to sleep, so she lay down with patient with fever or those on a heating blanket. She chose to sleep next to Morgan because she was giving off heat due to a carcinoid tumor hiding in her appendix. House is able to stop the brain surgery in time — and presumably Morgan has her appendix and tumor removed.

A very blah episode of House. Basically a weak copy of the themes of House versus God, with much less exciting medicine. The best part was Taub’s side story, and that — like a car crash — was painful to watch but you couldn’t look away. Poor guy.

This episode did inspire me to develop Scott’s Sign: If the cardiac arrest occurs off-camera, it’s not going to be a good show.

Their really weren’t any huge medical errors this week, but there was a great deal of confusing medicine, leaps of logic, and poorly explained reasoning. Since I didn’t have any major complaints this week, I’ll just go with minor complaints in blue and nit-picking in green:

It always amuses me when House, a show about a physician which prides itself on finding the most obscure presentation of a particular disease, limits itself to only looking for the most common causes a condition knowing it must be one of them (in this case, it was Cushing’s Syndrome having to be from an ACTH-secreting tumor in either the brain or adrenals. Sure, they’re the most common, but many other more obscure causes are known and this show thrives on obscure.)

All her MRIs and CT scans and no one ordered a scan of the abdomen, which would have found the tumor.

The purple urine/Strep bovis infection is quite a stretch. Strep bovis is one of the possible culprits in PUBS (Purple Urine Bag Syndrome — a condition seen in catheterized patients), but the evidence is far from convincing.

House seemed to be saying the Cushing’s explained the brown urine (which, incidentally, I can find no information on), but the team also told him they tested for every cause of brown urine, which would presumably include Cushing’s. So did they test or not?

Labyrinthitis is only very rarely treated with antibiotics. It is not treated with the Dix-Halpike maneuver either — Benign Positional Paroxysmal Vertigo is (though, admittedly, they do have similar presentations)

The medical mystery wasn’t given a chance to be interesting, so only earns a B-. The final solution was slightly clever, but relies on too many missed opportunities earlier, so earns a B. While there was nothing hair-rendingly bad about the medicine this week, there was nothing remotely commendable either, and so it is awarded a strictly average C. The soap opera was disappointing as well. The Taub scenes were painfully good, but the rest was just goofy. I give it another B-.

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The scores for this week’s House Challenge have been posted

This was a free comic produced by DC Comics and Schering in 1999. Although generally well written and illustrated, the underlying concept makes this a very bad comic.

A rare white orchid is on display at the black-tie dinner at the Gotham City Botanical Gardens and Bruce Wayne (Batman) and Tim Drake (Robin) are there to keep an eye on it. The reason? Poison Ivy has recently broken out of prison and this is just the kind of plant she likes to steal. Sure enough, she shows up and Batman and Robin spring into action. Unfortunately Robin is so sedated from his over-the-counter allergy medication that he lets Poison Ivy escape with the orchid.

When Batman and Batgirl head out to track down Poison Ivy and the orchid, Robin wants to come along, but Batman grounds him because of his antihistamine-related grogginess. Robin starts to sulk, but Alfred sends him to his doctor who prescribes him a non-sedating antihistamine (Claritin, of course — this was published when it was a prescription-only drug). Thanks to his new medication, Robin is able to conquer his hay fever and avoid sedating side effects; he joins the battle just in time to redeem himself by capturing Poison Ivy and rescue the orchid.

As giveaway comics go, the story by Christopher Priest is quite well done and Joe Staton handles the art well. What keeps it from being a good comic is the fact that Batman is selling drugs. Batman. Is. Selling. Drugs. Look, I don’t mind using super-heroes on occasion to sell something: subscription, Hostess snack cakes, Underoos, etc. I understand that bills have to be paid. But I draw the line at using super-heroes to sell drugs, even ones as innocuous as Claritin. There are some lines that just should not be crossed.

Two good episodes of House in a row, what are the odds? Sure, the medicine was a little sketchy, but overall it was pretty well done.

Natalie is a sixteen year-old overweight high school student and the victim of frequent bullying. At the school Christmas show, she develops visual hallucinations and vomiting. After admission to the hospital, she is found to have liver failure as well. The initial differential diagnosis is Wilson’s Disease, alcohol abuse, or something the other kids slipped her. Sure enough, some of the kids in the choir do admit secretly giving her a hallucinogenic mushroom. Additionally, a search of Natalie’s locker reveals a large bottle of acetaminophen (Tylenol) — an over-the-counter painkiller than can cause liver failure — raising the possibility of a suicide attempt. Natalie denies any suicidal thoughts or intentions, but Cuddy wants to go ahead and start her on acetylcysteine, the antidote for acetaminophen poisoning.

Next, Natalie develops a rapid heart rate and increased blood pressure, along with pulmonary edema (fluid filling up in the lungs). The differential now a toxic exposure (glue sniffing is mentioned), or infection. When House discovers she has been volunteering at a homeless shelter, he sends Taub to check it out. He returns suspicious that Natalie might have TB (tuberculosis) because one of the residents there has a severe case of it. About this time, Natalie has a seizure. Cuddy remarks that Natalie’s liver functions are very bad; she suspects hepatic fibrosis. Other possibilities mentioned include a severe mold allergy or a fungal infection. House has the team test for the allergy (the prick test) and start her on antifungal medication. The allergy test is negative. One of her “friends” from school visits and drops off some homework for her. He mentions that she used to be a heavy drinker, but stopped a few months ago. This again raises the specter of alcohol abuse, or possibly even alcohol withdrawal as it can cause seizures. Cuddy wants to start benzodiazepines (“benzos”) because they help with alcohol withdrawal, but her parents refuse. House decides to go ahead and start them, but not for alcohol abuse, but for her seizures (“wink, wink” — though they are used to treat seizures as well).

Natalie now passes out and is found to have a dangerously low heart rate. The differential shifts to multiple endocrine neoplasia, a hypothalalmic brain tumor, or leukemia. Wilson and Cuddy want to start treatment for the suspected leukemia, but House wants to wait for a bone marrow biopsy to confirm the diagnosis. Cuddy remains concerned that they may be missing something. She mentions autoimmune disease, particularly microangiopathic vasculitis (inflammation of tiny blood vessels such as capillaries and arterioles). When House tells her about a clinic patient of his, she has her own Eureka! moment and realizes that Natalie has eclampsia (toxemia of pregnancy). It was not caught initially because Natalie gave birth prematurely several weeks before her symptoms appeared and eclampsia has been known to occur several weeks postpartum. Unfortunately, the damage to her liver and heart are permanent and it is likely that Natalie will die in the next few days, particularly when the transplant committee turns down her case. On the bright side, Natalie’s daughter has miraculously survived — she was found by a homeless couple — and now Cuddy wants to adopt her.

The medicine was not particularly deep this week, but there was nothing I’d consider a big error. Minor complaints in blue, nit-picks in green.

Giving antifungal medications — which are universally hard on the liver — to a patient in liver failure is not a good idea.

You don’t give chemotherapy for leukemia without first determining what type of leukemia it is.
Surely the leukemia showed up on an ealier blood count. They did check a blood count, right?

Acetylcysteine is used for treating acute acetaminophen poisoning, not for treatment well after the fact.
Checking an acetaminophen level first would be a good idea — it’s an easy test.

Magnesium sulfate is the treatment of choice for seizures due to eclampsia (of course, it helps to know that you are treating eclampsia). Benzodiazepines are not as effective, though they do work.

What shot was Cuddy giving Natalie in the leg when she was having the rapid heart rate and high blood pressure? Any “code” medication should have gone in the IV (faster action).

Yes, eclampsia can occur after delivery — I was taught that it could occur up to six weeks later (and you’ll notice it was one of my original predictions for the show). The β-HCG (the hormone checked for in a pregnancy test) drops after delivery, and within a few weeks it generally is back to normal, so it is entirely possible to have eclampsia without a positive pregnancy test.

The medical mystery was modestly interesting this week and deserves an B. The final solution was good and earns an A. The medicine was shallow (lots of jumping to diagnoses that make little sense, no good testing), but not terrible. I’ll give it a weak B. The soap opera was well done — Wilson yanking the team’s chain and Cuddy’s happy ending were both high point, though I don’t buy Foreman/Thirteen — so I’ll give it an A-.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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A second episode of House in a row that felt shallow and superficial. There were two potentially great concepts in this episode: House kidnapping a soap opera star, and the hospital’s accreditation inspection, but both were essentially squandered in this disjointed episode.

House is convinced that Evan Greer, the star of his favorite soap opera, has brain cancer. House has noticed that Evan’s line readings are slower and he is pausing more which leads him to believe that Evan has bad peripheral vision from an occipital lobe brain tumor. So House does what any other self-respecting doctor would do: he kidnaps his patient by pretending to be a chauffeur.

Arriving at the hospital, House convinces Evan to let him run one test on him — a test of his visual fields to look for blind spots. House informs him that the test showed upper right quadrant blind spot and that he’ll need an MRI. Foreman picks this moment to show up and point out that House is lying and the test is normal. Frustrated, Greer leaves the room; House pauses a minute to grab something from Pyxis, then follows Greer onto the elevator. While having a conversation with Wilson, House reaches over and injects Greer with a sedative, knocking him out, so that the MRI can be performed. Surprisingly (to House at least), the MRI is normal and shows no tumor. Greer wakes up at the end of the test and is furious. He storms off to find Cuddy to complain when his right foot suddenly goes completely numb and he finds himself unable to walk. He is admitted to the hospital — officially, this time.

At this point the differential diagnosis consists of vitamin deficiency or a toxic exposure. Cameron suggests that Greer may have injured a nerve in his foot when he fell after House knocked him out and suggests an EMG. House order Kutner to pretend to perform the EMG (Electromyogram — a test that checks the conductivity of muscles and nerves), but Kutner decides to go ahead and runs the test for real. Meanwhile, House has the rest of the team watching old episodes of the soap opera for subtle diagnostic clues. Taub and Foreman think that there might be some slight neurological symptoms and suggest myxedema or demyelination. The EMG is negative, and Kutner adds atherosclerosis (hardening of the arteries) to the possible diagnoses.

House checks out Greer’s dressing room and talks to his female costar. He learns that even though Greer’s character likes his gin and tonics, Greer himself does not drink — in fact, he’s kind of a health nut. Housee also learns enough to suspect that Greer may be suffering from erectile dysfunction. House suggests that Greer has B6 toxicity and the resultant autonomic dysregulation from eating too many sunflower seeds. The team decides to test whether the impotence is physical or psychological by testing heart rate, blood pressure, and tumescence after giving Greer some pornography. He is able to have an erection, but he also develops a dangerously rapid heart rate that requires defibrillation.

The differential now includes sepsis, paraneoplastic syndrome, and Graves Disease (an autoimmune disease which leads to too much thyroid hormone), with the latter being the most likely. House wants to “nuke” Greer’s thyroid to stop the Graves, but the rest of the team actually wants to test for Graves first by performing a radioactive iodine uptake test. The test shows that his thyroid is normal, but that he is starting to develop kidney failure. Autoimmune diseases are now added to the differential. A short time later, House is talking to Greer and he finds him repeating old lines from the show and discovers that he actually believes himself to be his soap opera character. He is also running an extremely high temperature and has slipped into delirium.

The team now suspects that Greer is septic, in other words he has an overwhelming infection. They are just not sure what infection it is. Pneumococcus, Tetanus, Lyme Disease are suggested, as are fungal infections. House also mentions rat bite fever and listeria. Greer is started on broad spectrum antibiotics, but is not improving.

While helping Wilson shop for a bed, House had an epiphany. Greer is not septic, instead he a rare type of allergic reaction known as allergic vasculitis and he is allergic to the chrysanthemums in his dressing room. House wants to start him on high dose steroids, but Foreman points out that high dose steroids would kill him if her were septic. Cuddy eventually steps in and allows House to start the steroids, but runs some confirmatory allergy tests. After these tests are complete she informs House of the results — negative: Greer has no floral allergies. They return to the patient’s room ready to restart the antibiotics only to find that Greer has greatly improved; the steroids worked. Later, House realized that Greer is allergic to quinine, the chemical in the tonic water his soap opera character drinks.

I can understand why House thought Greer had a brain tumor — that makes at least a little sense (though I think a frontal lobe tumor would fit the suspected symptoms better than an occipital lobe tumor). The rest of the medicine in tonight’s episode barely made sense, and the team basically haphazardly stumbled from one unsupported diagnosis to another to another. Here’s what caught my eye tonight:

The final solution of allergic vasculitis doesn’t really fit the case well. The symptoms Greer had are rarely, if ever, seen in allergic vasculitis and he was missing the common symptoms such as the distinctive rash. I would also like to point out that the team dismissed an autoimmune cause because he had a fever, but no one batted an eye at a fever being caused by allergic vasculitis — another type of overly aggressive immune response (in truth, both autoimmune diseases and allergic vasculitis can cause fever. Just give me a little consistency in logic, please). And why was House convinced that chrysanthemums were the cause — where did that come from? On a daily basis, people are exposed to hundreds if not thousands of allergens, it could have been any of them.

B6 toxicity doesn’t match his symptoms either. It can cause nerve toxicity, but not like Greer had. Sunflower seeds do contain a large amount of B6, but he would have to eat a hell of a lot of them to develop toxicity. An ounce of sunflower seeds contains 0.23mg B6. Toxic doses start around 500mg/day, or over 2000 ounces of seeds per day.

Giving someone porn and then watching them to see if they get an erection is not the way to differentiate physical from psychological causes. That situation is enough to cause psychological impotence in anyone.

Graves disease is an autoimmune disease. An ANA is not the definitive test for autoimmune — there really isn’t any one single test. ESR (”sed rate”) is probably one of the most common, but if the team had run that, they would have figured out the vasculitis much sooner.

100mg of IV methylprednisolone (”Solu-Medrol”) is not that uncommon a dose. When high doses are needed, it’s generally an emergency (acute asthma attack, for instance) and having to wait for Cuddy to sign off on it is a delay in treatment and a lawsuit waiting to happen. And you’d think the pharmacist would learn to lock his door by now.

Ampicillin is not an appropriate drug for sepsis, particularly sepsis of an unknown cause.

Accreditation inspections involve a team of inspectors, not just one, and are not usually carried out on an annual basis unless there is a known problem.

I give the medical mystery a B+ because it was a clever idea: House deducing something is wrong just by watching an actor on television. Unfortunately, neither the final solution nor the medicine leading up to it were all that good; I give them both a C-. The soap opera was fairly average. There were a couple brief glimmers of cleverness, but nothing really memorable, so it deserves no more than a C.

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Tonight features the first of four new House episodes. It was a decently mediocre episode — not bad, but not particularly outstanding, either. Kind of “House Lite.” An episode recap, medical discussion, and spoilers follow!

Jeff, a carpet cleaner by trade, is spending his lunch hour with his wife, a nurse on the picket line in front of the hospital. While there, he starts to have nystagmus (twitching eyes) and then collapses. He is admitted to the hospital Emergency Room for evaluation, but — thanks to the chaos from the nursing strike — is given a low priority and basically sits there waiting for several hours. House, who is in the Emergency Room avoiding Cuddy, is perplexed by Jeff’s constant cheerfulness and niceness. He decides that something must wrong with him and admits him to his service for evaluation.

Jeff’s initial complaints are syncope (fainting), dysgeusia (altered sense of taste), and “niceness.” The altered taste (everything tastes like lemon meringue pie) and happiness have been present for eleven years. House suggests that Jeff may have a metabolic disorder, toxic exposure, carcinoma of the tongue which has spread to the brain, epilepsy, or multiple sclerosis. Taub suggests he just has the flu. House disagrees and orders Foreman and Kutner to search Jeff’s house for toxins, and tells Thirteen and Taub to check an MRI and EEG. The tests are normal, but the team searching the house finds carpet cleaning chemicals including hydrofluoric acid, which is known to affect calcium. From this, House deduces that Jeff has Williams Syndrome. Taub disagrees, pointing out that Jeff is missing some of the necessary symptoms to make the diagnosis including the characteristic facial appearance, lower than normal intelligence, and musical ability. While the team is arguing, Jeff suffers a stroke.

Thirteen suspects that Jeff has a heart defect (a patent foramen ovale) and this is what is causing his symptoms, but never gets the chance to run the test because the patient’s VDRL — a test for syphilis — has come back positive. The team now suspects that Jeff has neurosyphilis. He is started on penicillin to treat the syphilis, and a short time later he begins to vomit blood (”hematemesis”). According to the team, this could be from the syphilis, or it could be due to a reaction to the penicillin, carpet cleaners, or even alcohol. More tests are run and the patient is determined to have “hepatitis” — not viral hepatitis, but some other non-specified kind. House orders a test for sarcoid, and starts Jeff on steroids to treat the hepatitis.

Jeff’s wife returns to visit him, and he is uncharacteristically mean and angry. He then suffers a heart attack (which actually seems more like a cardiac arrest). The team considers the situation: is the rage due to the steroids (too soon; not as common on glucocorticoids as anabolic steroids), a penicillin allergy, a heart defect, or maybe his real personality finally re-emerging? In the middle of an echocardiogram to look for a heart defect, Kutner has an epiphany. The patient doesn’t have syphilis — he has another condition which gives a false positive VDRL result. Jeff has Chagas Disease, a rare parasitic condition (rare in the U.S., at least) which he picked up while in the Peace Corps. He has had a low-level encephalitis since then, and the immune suppression from the steroids caused it to flare up and his symptoms — the anger — worsen. He is started on the appropriate treatment and House assures him that he will be cured in a month — but what personality is the real personality?

I don’t have too much to comment about this one, medically. In this episode, the medicine was clearly secondary to the personality issues (What is Jeff’s real personality? and House vs. Amber). House and the team skipped over a bunch of more common causes of Jeff’s symptoms, going straight for the obscure. They then focused on these obscure causes, when some simple — and frankly standard of care — follow-up tests would have shown them their error from the beginning.

Syphilis antibody tests such as the VDRL are notorious for their false positives. That’s why you always run a confirmatory test such as the FTA-ABS, which was never done. For neurosyphilis, you should test the spinal fluid and not just the blood. Many different things can cause a false positive VDRL, not just Chagas Disease. The list includes HIV, Lupus and other autoimmune diseases, Lyme disease, mycoplasma, hepatitis, mononucleosis, and certain drugs.

Despite what House implies, cure rates for chronic Chagas Disease are dismally low. Treatment is not recommended for those who have been infected for over 10 years due to the low success rates (less than 25%). By this late in the disease, the damage to the heart and other organs has been done — this damage cannot be reversed, but can be fixed with appropriate medications, and in some cases, surgery.

I give the medical mystery a B+ because it brought up some interesting points — is being too happy a bad sign? And if so, is being too curmudgeonly equally bad? The final solution was moderately clever, but even more an out-of-the-blue answer than usual, earning a C. The medicine was weak and sloppy throughout and could have been handled better by a second year medical student; it deserves only a measly D. The House/Amber/Wilson/Cuddy soap opera was good, the House-has-syphilis not as good. Still, I give the soap opera aspect a generous A-.

(And as an aside, why would House and Amber submit to Cuddy’s punishment? When has House ever done anything Cuddy has said, and what power does she have over Amber?)

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

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

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

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

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

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

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

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

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

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

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Funniest Line (intentional):

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

Funniest Line (unintentional):

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

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

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

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

The first episode of House’s fourth season begins with — well, not a bang, but not a whimper, either — more of moderately exciting spectacle, like one of those fireworks that trickles down rather than explodes outward. In this episode, bereft of a team, House must solve a case on his own. Mostly.

There are definitely spoiler warnings ahead, especially for the ending, so don’t read if you haven’t seen the episode. Or if you do, don’t whine about it afterwards.

As the episode starts, a young woman named Megan is at work talking on the phone to her boyfriend, Ben. He is trying to persuade her to go to a movie that evening, but she declines, citing fatigue and sneezing. She tells him that she thinks she’s having hallucinations because the building seems to be shaking. There is a sudden roar as her office building collapses in a gas main explosion.

It’s now two days later. Megan is one of the few survivors of the explosion, but she is still very severely injured. She has been through multiple surgeries for fractures and burns. Cuddy consults House because Megan has been running a persistent fever despite being on antipyretics (fever reducing medication like acetaminophen or ibuprofen). She has also been lapsing in and out of consciousness. Cuddy wants to use this case as a goad to get House working with a team again, but he refuses. He cuts her a deal: if he can solve the case by himself that day, she will not bug him for a week.

House ropes a passing janitor into helping him. He describes the case to him in mechanical terms, and asks him what he would do. The two of them come up with several possible diagnoses: brain damage with hypothalamic dysfunction (which House discards because it would have shown up on the brain MRI she already had), infection (possible parasitic or fungal infection, admits House), or Lupus (the janitor’s grandmother had Lupus). House wants to break into Megan’s house, but the janitor refuses (or at least refuses for the amount of money House is offering him). In the end, House shanghais Wilson to help him search the house. They find a diary which reveals that Megan had a history of fatigue and feeling blue. From this, House infers that Megan has depression. He then makes the leap that she was on a certain kind of antidepressant (an MAO Inhibitor — a class of antidepressants used only rarely, if that, because safer more effective drugs are now available), that when combined with Demerol (a narcotic pain killer) she received in the ER, can cause Serotonin Syndrome, of which fever is one symptom (This is true, but there are other symptoms of Serotonin Syndrome which should have shown up as well. Serotonin Syndrome appears rapidly, and should have shown up within a few hours of receiving Demerol, and should have resolved by now, several days since she has had either antidepressants or Demerol.) House decides to place Megan on dialysis to remove the drugs from her system (not a common treatment for Serotonin Syndrome, but it has been used in severe cases). Her boyfriend insists that Megan was not depressed, seeing a psychiatrist, or on antidepressants, but House believes that Megan was just hiding it from him. He gets her mother to sign the consent.

After the dialysis she wakes up and confirms through blinking that she was seeing a psychiatrist and was on an MAO Inhibitor. She then develops ventricular tachycardia and slips into unconsciousness and cardiac arrest. Cuddy has to defibrillate her back into a normal rhythm.

House considers his deal with Cuddy done and himself the winner, but Cuddy disagrees. She wants him to figure out why Megan developed tachycardia. Endocarditis (an infection of the heart) is considered at first, but discarded because blood cultures were negative. Cuddy and House now consider that Megan may have cardiac damage from Crush Syndrome. Crush Syndrome occurs when a patient has been trapped under a heavy object, crushing part of their body and cutting off blood flow. The damage from the crush injury causes an increase in toxic chemicals in the affected parts of the body. When the patient is then released from the heavy object and blood flow resumes, these chemicals circulate throughout their body, causing a variety of serious problems (She’s been in the hospital for 3 days at this point, routine labs should have shown any Crush Syndrome by now; it’s not going to show up suddenly this late). House and Cuddy suspect the high potassium from the crush injury combined with “microvascular occlusion” have caused the heart problem, but luckily, this will show up on an echocardiogram. The echocardiogram is obtained, but it is completely normal. Taking the tachycardia (but normal echocardiogram), sweating, and fever into account, House now decides that Megan is suffering from delirium tremens (alcohol withdrawal). Her boyfriend again objects, saying that he would have noticed if she were an alcoholic. House ignores him and starts her on IV ethanol, which does correct her fever and tachycardia. In real life, IV alcohol is not the recommended treatment for delirium tremens because it doesn’t solve the dependency problem, just prolongs it. Plus, it can lead to electrolyte abnormalities (which Megan already has), gastritis, pancreatitis, and hepatitis. Benzodiazepines (such as Valium, Ativan, or Librium) are the treatment of choice.

When Cuddy visits Megan and her family, she realizes that Megan has been silently screaming in pain for the past 2 hours (but apparently the pain wasn’t enough to raise her blood pressure or heart rate noticeably). Labs show an elevated amylase and lipase, meaning that Megan has developed pancreatitis. The alcohol was the most likely cause for the pancreatitis, but there can be other causes as well. House obtains an MRI which shows a normal pancreas (when it should at least show pancreatitis). The MRI also shows an abnormality around the liver consistent with blood. Sure enough, Megan starts to bleed out both ends and is rushed to surgery with multiple sources of internal bleeding. Watching the surgery, House notices that Megan has an enlarged uterus. He enters the OR and takes a look, realizing that Megan has had a recent abortion. He then hypothesizes that she has been taking birth control pills, which when combined with the Warfarin (a blood thinner) she has been on since hip surgery (which would have been nice to know earlier), led to her bleeding (The effect, if any, oral contraceptives have on Warfarin is not clear. The combination probably does slightly increase the risk of bleeding, so House may be right. Of course, every other medication mentioned in this episode — including MAO inhibitors, ethanol, cephalosporins, tamoxifen, and antipyretics — also increase the chance of bleeding while on Warfarin, only moreso). House puts her on Tamoxifen to block the effects of the birth control pills (this is not a recommended use of Tamoxifen). This revelation that Megan had an abortion is too much for her boyfriend, who leaves the hospital, but he return later to sit by her side.

The bleeding improves, but now Megan develops kidney failure and breathing problems. Her fever returns. House wanders the ER looking for a doctor to bounce ideas off, but discovers that Cuddy has put out a memo prohibiting anyone from talking with him. One young resident decides ignore the memo and talk with him anyway. At first she suggests a fungal infection or haemophilus infection, but House rules these out. She then mentions Crush Syndrome (which House states wouldn’t explain the breathing problems) and ARDS (Adult Respiratory Distress Syndrome — which House complains would only explain the breathing problems). House rethinks the differential diagnoses, and now concludes that the patient is suffering from both Crush Syndrome and ARDS, which is bad news for Megan since these conditions have a poor prognosis. As he is talking with her mother and boyfriend, he notices a large lump in her arm. An MRI shows multiple similar lumps scattered throughout the body which are shown to be Eosinophilic Granulomas, which they say is a sign of an allergic reaction (I don’t know what they are referring to here. Eosinophilic Granuloma is a type of Langerhans Cell Histiocytosis, a rare disease that has nothing to so with allergies. I’m wondering if they are confusing it with feline eosinophilic granuloma, a very different condition.) Apparently Megan is allergic to the antibiotics she was given in the hospital — medications which she has taken before without any problem. Finally, House realizes the solution to this patient’s problems — she isn’t Megan. Both Megan and a similarly appearing girl named Liz survived the explosion. There was a mistaken identification and Megan was identified as Liz and vice versa. Megan died several days ago, and the patient House has been treating is Liz — whose medical records confirm everything House has suspected including the antidepressants, abortion, and use of birth control pills.

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Overall, House seemed to jump from diagnosis to diagnosis, ignoring almost everything he learned previously, building a precarious (if medical) house of cards. That he was correct was almost entirely luck, not skill. I’m sure most of this was intentional by the writers, to show that House needs a team, but it made for some very disjointed medical care.

For those who may think that the patient mis-identification at the end was a stretch, I know it seems hard to believe that family members wouldn’t recognize their child/significant other, but it has happened more than once. There was a very similar case about a year and a half ago featuring Taylor University students injured in a van crash. I suspect it was the basis for this part of the episode.

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I give the medical mystery a B+, because it was interesting, if ultimately a little misleading. The final solution I give a B+ (the wrong patient solution, not the allergy solution, that was a D) because it fit the situation well, better than many past solutions. The medicine was sloppy, haphazard, and sometimes just plain wrong. Even if that was intentional, it only deserves a C-. The soap opera was the good, particularly the scenes with Cuudy as well the janitor. I give it another B+.

A list of all prior House reviews

Tags: television medicine house depression crush syndrome ards

It’s prime ragweed and hay fever season here in the Mid-West. My most common reason for patient visits this week has been allergies.

Allergies are no fun for anyone, but there’s definitely certain characters for whom allergies would be even worse. Here’s the list I came up with:

Tigra
Doctor: “I’m sorry Ms. Grant, but you’re allergic to cats.”

Thor
“Forsooth! Mine sneeze hath leveled that house!”

M.O.D.O.K.
Just imagine all the snot that would come from that giant nose. Come to think of it, I’m actually surprised that no one has written a story where M.O.D.O.K has allergies (or would that be M.O.D.O.S.* or M.O.D.O.R.N.I.E.S.**?).

Dr. Doom
Just try sneezing inside a metal face mask. Would also apply to Iron Man, Crimson Dynamo, War Machine, etc. etc.

All-star Batman
“I’m the godd – ACHOO!! I’m the go – ACHOO!! I’m the – ACHOO!! Eh, forget it.”

Superman
Itchy, watery eyes interfere with x-ray vision. If you want to rob a bank in Metropolis, do it during allergy season.

Madrox
Every time he sneezes, a double is formed.

Wolverine
Hard to track by scent when you’re all stuffed up.

The Human Bomb
Pretty self explanatory.

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*Mental Organism Destined Only for Sneezing
**Mental Organism Destined Only for Runny Nose, Itchy Eyes, and Sneezing

Apothecarius Argentum is a manga recently published by CMX. It concerns Primula, the princess of the medieval Kingdom of Beazol, and Argent, the local apothecary (a cross between a pharmacist, physician, and healer). Argent is a Basilisk — individuals who were purposefully fed potent poisons as children. They subsequently develop immunity to toxins and their touch is poisonous. Argent was originally a slave who was bought by the king to be his daughter’s food taster. Later, when he accidentally touched the princess while saving her life, he was sentenced to death but Primula let him escape. He has now returned to the kingdom years later as an apothecary.

The book is a good read. It contains four independent chapters which involve (as one might expect) poisonings, fights, and palace intrigue. Argent is an interesting character, and the princess and her father have potential, but still need more development. The art is competent, but not outstanding — it seems sketchy at times, particularly when the princess is the subject. The medical aspect is quite good as the writer worked as a pharmacist before becoming a mangaka. He provides some interesting endnotes. My main complaints are relatively minor. I wish the Kindgom of Beazol were better developed as it plays an important part of the narrative, yet seems no different than any other generic genre quasi-medieval kingdom. The book seems a little thin to me as well, at least compared to other manga. I’m not sure if it has fewer pages or thinner paper (or it might just be my imagination).

There are some minor spoilers below, so I suggest you read the manga before perusing my medical annotations…

Chapter 1
1. The symptoms of mercury poisoning vary depending on what form the mercury is in: elemental, organic, or inorganic. Symptoms can also vary based on the length of time of administration — was it a large dose at once, or many smaller doses over a long period of time? — as well as the route of administration (inhaled or ingested).

The villain tells the princess that he has been slowly and methodically poisoning her food, so she has chronic ingested mercury poisoning. Her symptoms match those of inorganic mercury (mercuric salt) poisoning. The princess’s complaints include nausea, vomiting, pale mucous membranes (the gums and inside of the cheeks), and edema in the arms and legs. Inorganic mercury poisoning causes ashen gray mucous membranes due to the deposition of mercuric salts. Gastrointestinal symptoms are common including nausea, vomiting, stomach pain, and even bleeding. Inorganic mercury poisoning can also cause a strange condition known as acrodynia. Patients with this have red palms and soles, as well as edema of the arms and legs. More severe cases can lead to hair loss, a peeling rash, and cardiac and neurological problems. Acrodynia is thought to be due to a mercury allergy. Based on the princess’s symptoms, Argent was correct, and she has a (conveniently) minor case of chronic inorganic mercury poisoning with symptoms that include early acrodynia.

Treatment of symptomatic mercury toxicity requires chelation. A special medication is given which binds to the mercury and allows the body to excrete it. The most common modern chelating agent is given by intramuscular injection, but there are oral chelating agents available as well.

2. Later in the chapter, Argent is poisoned with an arrow dipped in curare. The villain gloats over his downed body:

Curare is a highly potent poison derived from the vines of a tropical plant used by foreign savages. When struck by a poisoned arrow, it causes gradual muscular paralysis. You will soon die of respiratory failure!

The bad guy has it right. Curare was used as a dart poison by certain South American tribes. It is a potent muscle paralyzer — high doses cause asphyxiation because the victim’s respiratory muscles stop working. Modern medicine still uses curare and some of its derivatives as paralyzing agents before surgery or intubation.

3. Cowslip(Primula veris) is a common flowering plant in Asia and Europe. It has many reputed uses as medicinal herb, including use as a sedative, like Argent mentions.

Chapter 2
1. While preparing for a speech, the princess steps on a deliberately placed rusty nail. She soon develops a fever and becomes sick. Given the speed with which the infection hit, the nail was likely treated with some form of infectious agent. In the United States, whenever we hear “rusty nail,” we think of tetanus, but her symptoms and quick recovery do not match that disease. It makes me wonder if the “rusty nail equals tetanus” implication exists in Japan as well, or if its use was just coincidence (or a red herring).

2. Argent is right that sulfur gas can cause optical problems (blurry vision) and respiratory irritation. It doesn’t cause the respiratory arrest and death he threatens though. In the end, he admits that he is lying about the medication he gave, so he could easily be exaggerating about the effects of sulfur as well (or he might be confusing it with sulfur mustard, i.e. mustard gas, a chemical warfare agent first used in World War I.)

Tags: comics medicine apothecarius argentus manga mercury curare cowslip tetanus sulfur mustard gas

A nice brisk episode of House with two good medical mysteries. One involves a woman hospitalized with neurological symptoms, and the second involved House and Cuddy stranded on a plane with a possible meningitis epidemic. Spoilers follow, so make sure you watch the episode first…

The first story concerns a 58 year-old woman who presents to the clinic after suffering blurry vision and a fainting spell. Her medical history is negative, except for a recent trip to Caracas where she went a little wild and indulged in drugs, sex, and — one presumes — rock and roll. Wilson finds a scopolamine patch (used to treat motion sickness) behind her ear, and blames the symptoms on this. He removes the patch and sends her on her way, but she has a seizure as she leaves the clinic. She is admitted to the hospital and the team’s initial thoughts are that she either has a neurological problem of some sort, or an allergy. Wilson orders a drug screen, a head CT, a chemistry panel, a blood count, and a screen for STDs (sexually transmitted diseases). He also has Cameron and Chase search her house for toxins or allergens.

The search of the house turns up nothing, the head CT is negative, and the blood tests are also negative. Wilson deduces that she must be have paraneoplastic syndrome (a rare condition where the body’s immune system over-reacts when a cancer is present) from an undiagnosed breast cancer. He orders mammograms, but as Fran is suffering through them, she develops a sudden blindness in her right eye. This makes the cause more likely to be neurological than cancer. An EEG with evoked potentials is obtained, and as the test is proceeding, Fran falls into a sudden coma. Foreman believes she has increased intracranial pressure from a bleed and that is the cause of her symptoms. He wants to drill a burr hole in the skull to relieve the pressure. Cameron is skeptical of a bleed (and rightly so) since it didn’t show up on the CT scan. She wants to perform an LP (lumbar puncture, also known as a spinal tap) to look for signs of bleeding or other causes before they drill into Fran’s skull. The spinal fluid apparently supports Foreman’s bleed theory (yet it looked clear to me), and the team proceeds to surgery (and since when is Foreman a neurosurgeon?). Meanwhile, Chase remembers that Fran’s cat seemed to have lost its appetite, and Fran didn’t each much in the hospital either, and thinks these might be clues. He re-examines Fran’s house, and finds an old pipe that leads from her house to a neighbor’s house — a house which had just been fumigated with methyl bromide. The surgery is stopped in time, and with supportive care, she recovers.

The second story occurs on a plane — a plane that House and Cuddy just happen to be flying on back from Indonesia. Mr. Peng, the passenger next to House becomes violently ill with a fever and vomiting. Upon examining him, Cuddy notes abdominal pain and a splotchy red rash on his lower back and believes that he has bacterial meningitis (a very contagious and frequently fatal disease).

Another passenger, a young woman this time, becomes sick with the same symptoms. Enlisting three passengers as stand-ins for the Young Guns, House lists other possible causes, including organophosphate poisoning, jet lag, a Dramamine overdose, a DVT (deep venous thrombosis — a blood clot in the leg) and food poisoning. He suspects that it is ciguatera poisoning from the sea bass served for dinner, but Cuddy still maintains it is meningitis.

They re-examine Mr. Peng, and House notices that one leg shows a history of a fracture and wonders if maybe the patient has radiation sickness from too many x-rays. With little warning, Cuddy herself becomes sick with vomiting, rash, abdominal pain, fever, and photophobia (eyes that are sensitive to light). In addition, 3 other passengers become sick. House collects all the medications he can from the remaining passengers and finds only a few useful antibiotics (though he does diagnose a herpes infection along the way).

Cuddy continues to insist that the cause must be meningitis, but House is still not convinced. He decides to improvise and perform a lumbar puncture using available equipment on Mr. Peng. He collects his sample, and immediately enters the main cabin, grabs the intercom, and announces to the passengers that there is a meningitis outbreak aboard the plane. He advises them all to look out for symptoms including abdominal pain, nausea, and left hand tremor. This is a ruse on his part — the spinal fluid was clear (infected spinal fluid would be cloudy) so there was no meningitis. His ruse was to show that people on the plane were panicked and easily suggestible, and everybody who had symptoms (except Mr. Peng) was suffering from conversion disorder (in other words, they thought they must be sick, so they subconsciously became sick. They never had any physical disease.)

House now turns his attention back to the only truly ill patient, Mr. Pengm. His differential diagnosis includes head trauma, cerebral infarction (stroke), and cerebral hemorrhage (bleeding in the brain). Cuddy suggests syphilis. This causes House to think of condoms, and he now believes that Mr. Peng must be a drug mule — a person who smuggles drugs stored in swallowed condoms. He thinks one of the condoms must have burst open and Mr. Peng is suffering from acute cocaine poisoning. He is ready to operate when he notices that applying pressure to Mr. Peng’s joints relieves the pain. He now realizes that Mr. Peng is suffering from the decompression sickness, better known as “the bends“. He had gone SCUBA diving on vacation and had ascended to rapidly. The low pressure in the airplane exacerbated his symptoms. House has the pilot fly at a lower altitude and places Mr. Peng on oxygen. This will help until he can get to a hospital equipped with a decompression chamber.

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I felt the medicine was decent this time, particularly the airplane scenes. I do have a few concerns about Fran’s care. First, why did the ambulance take her to the clinic? Shouldn’t she have gone to the ER (unless it’s an acute care clinic that’s part of the ER)? Wilson and the Young Guns seemed to lose their focus after the initial tests came back negative and lurched from diagnosis to diagnosis, but we’ve seen that before. Cameron was right, and any bleed substantial enough to raise intracranial pressure enough to cause a coma would show up on a CT scan — and even if it didn’t show up on the first CT scan, it would be reasonable to repeat the scan after her condition worsened. When Chase performed the LP, since the team was concerned about intracranial pressure, he should have checked for opening pressure. Speaking of the LP, the fluid sure looked clear to me. Presumably, Chase and Cameron saw blood and felt that this meant Foreman was right. Of course, blood in the fluid could have come from the tap itself, and not the brain. Maybe he saw xanthochromia (a yellowish discoloration of the spinal fluid from broken down blood cells), which can suggest a cranial bleed has occurred, but it usually doesn’t appear until about twelve hours after a bleed. Finally, I wonder if Fran really would have survived. There is no treatment for methyl bromide other than supportive care, and the fact that she got worse even after being removed from the source makes me suspicious the damage had already been done.

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Both of tonight’s medical mystery were good and deserve an A. The solutions fit the cases and earn another A. The medicine was a mixed bag, a B- for the hospital plot, and an A for airplane plot, so I’ll give it a B+ overall. The soap opera aspect was decent — not terribly exciting, but not bad either — and earns a B.

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Tags: television medicine house methyl bromide meningitis decompression sickness

An enjoyable episode of House. The mystery was good and the medicine passable. The soap opera and personal dynamics were the highlights this week, and it was was one of the best episodes yet in this regard. Stay tuned for this week’s House medical review (and spoilers)…

Alice is on a ride at a fair with her father when she starts screaming. He thinks it’s because she’s scared of the ride, but she keeps screaming even after the ride is over. There is an abrupt cut (and the title and a commercial) and we discover that Alice was having severe abdominal pain and was admitted to the hospital after it was discovered she was suffering from acute pancreatitis. The Young Guns are having a debate about whether the pancreatitis is caused by an infection or gallstones when House strolls in, notices the dilated bile duct (a sign of a gallstone, either current or recent) on Alice’s CT and informs them that a gallstone is the cause of her pancreatitis. An abdominal ultrasound confirms the presence of gallstones. House wants Alice to undergo surgery to remove the gallbladder; the father agrees but the mother does not. They go before a judge who reluctantly sides with House (though it should be noted he greatly overstates the risks of not having the surgery).

The next morning, Alice has a nasty looking vesicular (blister-like) rash at the surgical site. The team suspects allergies and has Alice undergo a scratch test, which is a test that looks at a whole range of possible allergens. She turns up positive to everything. The team is concerned, but House thinks she has an infection of some kind that is influencing the allergy test. He wants to treat her with a broad spectrum antibiotic. This time, the mother agrees and the father does not. They appear before the judge again who awards temporary custody to Cuddy. She, in turn, does not want to use a broad spectrum antibiotic but instead decides to use metronidazole (Flagyl).

Alice is abducted from the hospital by her father, but he brings her back quickly when she becomes stiff shortly after leaving the hospital. The differential at this time includes neuraxonal dystrophy (a term describing certain types of acquired brain damage) and Wilson’s Disease (a condition caused by impaired metabolism of copper), though House suspects Reye Syndrome (a rare encepholapthy usually associated with the use of aspirin during a viral illness in children). He starts her on charcoal hemoperfusion (similar to dialysis, it removes toxic particles from the blood) to treat the Reye Syndrome, but she develops a blood clot and her left arm becomes pale and painful. She is taken to surgery and the clot is removed, but she runs a dangerous fever. The team is now concerned about thrombocytopenia (a severe decrease in platelets, in this case thought to be caused by the blood thinner she was placed on for the hemoperfusion), though House continues to fixate on an infectious cause. It is also noted that she is anemic. Alice develops another nasty rash, similar to the first one, this time on her left arm and then her left leg. Varicella (Chicken pox) is considered, as well as Rickettsialpox and Rocky Mountain Spotted Fever (RMSF). She is started on chloramphenicol to treat the suspected RMSF. It does no good, and when the rash spreads, House decides that she Alice is actually suffering from necrotizing fasciitis, the infamous “flesh-eating bacteria”. A key component of treating necrotizing fasciitis is to remove any dead tissue, so they schedule Alice for amputation of her affected arm and leg. At the last moment, Chase realizes that she does actually has congenital erythropoietic porphyria, a rare disease where exposure to sunlight or other bright light breaks down blood cells causing increasingly severe symtpoms. The surgery is stopped in time (but not before House decks Chase).

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Medical Thoughts (both good and bad):

• The clot appears to be arterial (a painful, pale, cold extremity), but she had venous access for the hemoperfusion.
  Metronidazole was a poor choice of antibiotic. It is good against a small spectrum of pathogens, and none that matched Alice’s symptoms.
• Alice’s symptoms don’t really match up well with Reye Syndrome. Charcoal hemoperfusion is not the treatment for Reye (though its close cousin hemodialysis can be used in severe cases).
• Chloramphenicol, though an old and rarely used drug, is the first line treatment of RMSF in children.
• While necrotizing fasciitis does require the surgical removal of dead tissue, it does not require amputation — that’s going way too far way too fast (and what about the fact that the rash first appeared on her abdomen — are they going to amputate her belly?). Despite what Cameron says it is not resistant to antibiotics and she, if not House (an infectious disease specialist, after all) should know better. House is right in that necrotizing fasciitis is an incredibly rapidly spreading infection and time is key.
• I liked the fact that House kept his secret secret secret stash of Vicodin in a textbook on lupus, because “it’s never lupus.”
• My biggest complaint is it took the team too long to arrive at what should have been an easier diagnosis (the general diagnosis of “porphyria” at least — though maybe not the specific porphyria right away).

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The best part of this episode was undoubtedly the soap opera. You had Tritter against Foreman, Tritter against Cameron, and Tritter against Chase, showing Tritter to be an incredibly shrewd and manipulative person. You had House versus everyone as the pain and narcotic withdrawl made him increasingly irritable. There was the nice Wilson/Cuddy moment and then the haunting Wilson/Tritter moment at the end of the episode.

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I give the medical mystery a B+ and the ultimate solution a B. The medicine was slightly above average, so I give it C+ (the team should have caught porphyria sooner, and Cameron should know better about necrotizing fasciitis). The soap opera/non-medical content earns a strong A this week, and was damn close to an A+.

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Tags: television medicine house porphyria necrotizing fasciitis

House returns with a well done episode with some of the best medicine yet. There is a high “ick-factor” this week, so consider yourself warned when you watch the episode or when you read this week’s House medical review.

Tracy and Jeremy, a young married couple, are eating in a diner when two gunman try to rob the restaurant. Tracy is held hostage, but Jeremy manages to rescue her. After subduing the gunman, he turns around to finder her gasping for breath in anaphylactic shock.

House’s team picks up the case four days later. In addition to the swelling of her throat, Tracy is also experiencing abdominal pain. She has been on steroids and antihistamines the four days she has been in the hospital and has shown some improvement. Allergy tests were negative and a laparoscopy has already been performed and was also negative. The initial differential diagnosis is pregnancy and allergies, both of which are ruled out by testing. Her urine drug screen did show evidence of marijuana and the team speculates that she could have been exposed to Salmonella through contaminated marijuana. She is started on a fluoroquinolone (an antibiotic such as Cipro, Levaquin, or Floxin) to treat the suspected Salmonella.

She develops a rash from an allergic reaction to the antibiotic (an allergy that happened way too fast, by the way). The team now discusses allergies as a cause again, but House suspects exercise induced anaphylaxis. Tracy is placed on a treadmill. She has some abdominal pain, but the test is negative. On the other hand, her husband develops severe chest pain and abdominal pain and finds himself admitted to House’s service. His initial work-up is negative — no heart attack or aortic dissection — and the team thinks it might be psychosomatic or a panic attack.

Then the team makes the assumption that both Tracy’s and Jeremy’s conditions are related and share a common cause. It seems like quite a stretch in logic to me at this point, but it’s not my show. A search of their apartment turns up a box of condoms so Chase and House suspect the cause is Gonorrhea, but all STD tests are negative.

Tracy’s pain is worsening. She goes into acute delirium and hallucinates about Jeremy’s father. She then slips into a coma. An MRI shows some generalized swelling as well as some suspicious spots in the brain stem, but it doesn’t give enough information for a firm diagnosis. House is concerned about sarcoidosis, though he also mentions plaques (multiple scelerosis, Alzheimer’s) and tumors. He starts the pair on methotrexate to treat the presumptive sarcoidosis, but he also wants a biopsy of Tracy’s brain. This sets up an ethical dilemma. Jeremy would normally be able to make medical decisions for Tracy when she is incapacitated, but since the decision will also affect his health, there is a conflict of interest. Another guardian must be declared, but that will take time. House ignores this and sends the team to talk to Jeremy, but he refuses to let them biopsy her brain. House wants to browbeat him into agreeing, so he uses naloxone to counteract Jeremy’s pain medicine. Despite House’s ploy, he still refuses.

Jeremy is not showing any brain symptoms, but he starts showing an elevated lactic acid, which can be a sign of an ischemic bowel (intestines that are not getting enough blood supply. This can proceed to death or infection of the intestines.). The team is concerned that his bowel is dying, so they operate expecting to have to remove some bad bowel. Surprisingly, they find no dead bowel, just swelling of the intestines. House now wonders if maybe it is two separate diseases: Tracy has small cell vasculitis, while Jeremy has porphyria. He then makes one of his patented logical leaps and realizes that they both have a rare genetic disorder called Hereditary Angioedema that leads to the swelling of body tissues, particularly in times of stress. He then takes it one step farther and realizes that Tracy and Jeremy share the same father and are in fact half-siblings, this giving us our ick-factor of the episode.

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Overall, the medicine was sound. I have a few complaints, most of which I mentioned above, but no deal breakers this week. Most of the mistakes were jumping to conclusions too quickly without any real evidence, but that’s par for the course on this show. The team also went to surgery too quickly, both on Tracy’s laparoscopy (though that was the previous team), and on Jeremy’s bowel surgery. (And why didn’t they see edema during Tracy’s surgery?). I feel I should point out that the Young Guns did not perform any unrealistic testing themselves this week (the treadmill was a test I would expect them to run); since I always criticize them in this area, I will compliment them for getting it right this week. Additionally, lupus was not mentioned this week, nor was “autoimmune disease.”

Some nice soap opera this week. All three of the Young Guns, particularly Foreman, are standing up to House more. There is a clever sub-plot involving Wilson and a pediatric nurse, as well as House’s continues insistence that Cuddy is pregnant. David Morse also appears as a taciturn and disgruntled patient of House. He lodges a complaint, but House rebuffs him. In the final scene, House is speeding down the street on his motorcycle when he is pulled over by a cop — one that just happens to be Morse. House ends up arrested for possession of narcotics (this scene would have had a lot more punch if FOX hadn’t spoiled it by showing it in every preview for the past month).

I give this episode a B for the mystery, but an A for the solution because it was clever and supported by the signs and symptoms of the patients. Surprisingly, I award the medicine an A — a weak A, but an A nonetheless. The soap opera/non-medical aspect was good and deserve a B+.

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Tags: television medicine house sarcoidosis angioedema.

No major plot spoilers, but still it’s best to be forewarned:

First off, I enjoyed the movie very much. I thought Brandon Routh did an excellent job as Superman and the rest of the cast were quite good as well (Jimmy’s bow tie/plaid shirt combinations were too much though; no man is that color blind). The airplane/shuttle rescue scene was probably the best pure superhero scene I’ve seen in a movie yet. My main complaint is the villain. I just don’t think the movie Lex or his real estate plots are villainous enough to make him the needed supervillain. Or to put it more bluntly, as my wife did, the movie “needs more punching scenes.”

A couple of medical scenes did catch my eye…

1. Inhalers
Jason was using his inhaler wrong. He should not hold it right up to his mouth, but instead should hold it about an inch in front of his mouth. Ideally, he would get a tube known as a spacer to attach to the end of the inhaler so he would always use it at the correct distance.

2. Superman In The Hospital
First, remember the ABCs.
A (Airway) – Did Superman have a good open airway? In the beginning of the scene, the EMTs were holding his head in the proper position, but by the end they weren’t. Placing an endotracheal tube (ETT) would have been a good idea.

B (Breathing) - Good.

C (Circulation) – Not as good. I noticed nobody was perfoming CPR, but then he is the “Man of Steel” so it’s likely no one would have had the strength required for a good chest compression. The nursung staff tried to place an IV but couldn’t get the needle through his skin. (This is where the endotracheal tube I mentioned earlier would have been nice because you can put several of the resuscitation medications down the tube. It’s not as good as an IV, but it’s better than no medicine.) But then the doctors comitted Comic Book Writer Medical Error #3: they shocked a flatline*. Sure, it looks dramatic, but it just doesn’t work.

Second, it’s not in the ABCs, but given that Superman just sustained a major trauma, they should have brought him in on a backboard and in a cervical collar.

UPDATE: Forgot to mention that on the positive side, every medical provider in the ER was wearing eye protection.

*It sure looked like a flatline to me. However, later, when Lois visited him in the hospital, he was showing bradycardia (an abnormally slow heart rate) on the monitor, so maybe he just had a very very slow heart rate in the ER. In the case, the difference is moot because you don’t shock bradycardia either.

Tags: comics medicine superman superman returns inhaler

A clever mystery, and some interesting ethical debates made this a good episode of House. There are some major spoilers for this week’s episode of House below, so read at your own risk.

Hannah, a twenty-five year old woman, can’t sleep. She has not been able to sleep for ten days. She tells her girlfriend Max that she’s going to get a glass of wine and will be right back. When her girlfriend wakes up in the morning, Hannah’s not in bed; instead, she finds Hannah banging her head against the wall after taking an entire bottle of sleeping pills and still being unable to sleep. Hannah is brought to the hospital and assigned to House’s team.

The doctors’ first thought is infection, schizophrenia, or drugs – but they are all ruled out rather quickly (and frankly, not rather well. A single blood count doesn’t rule out a hidden or low grade infection, and there is no simple test to rule out a mental disorder). Next they wonder if it might be a visual perception issue, so they take a look at Hannah’s retinas and optic nerves. While performing the test, Foreman and Cameron notice that Hannah is sleeping, just in little 10 to thirty second intervals that she’s not even aware of.

A CT of the head shows no tumor, clots, or seizure disorders (which is impressive, as CTs don’t show seizure disorders) and the eye studies are normal. House’s plan now is to purposefully keep Hannah awake and see if they can provoke more symptoms. It His plan works too well: they quickly notice bright red rectal bleeding. With these symptoms, the concern becomes a clotting disorder or a tumor in the colon. Chase performs a colonoscopy but it is essentially normal. (Given that House wants to keep Hannah awake, I can see why they would not sedate her during the procedure, but there’s still no reason they couldn’t give her some pain medication). During the procedure, Hannah develops a copious nose bleed. She is transfused with 2 units whole blood (most physicians would have used packed red blood cells instead of whole blood, but whole blood is a theoretically better for people with clotting disorders and that might be why they chose to use it). An examination of the rectal blood reveals nasal epithelial cells, suggesting that the blood came from the nose (Generally, upper bleeding that comes through the gastrointestinal tract ends up dark maroon, black, or coffee ground in appearance due to the digestive process. Bright red blood like this patient had suggests a lower gastrointestinal tract bleed).

The differential now includes a toxin or a coagulopathy (another name for a clotting disorder). Some more history comes to light: shortly before she began having sleeping problems, Hannah had a rash diagnosed as poison ivy, and was given a dog by Max as a gift. The rash resolved on a dose of steroids, and the dog was returned because Hannah was allergic. House begins to suspect Wegener’s Granulomatosis. As Cameron is performing an upper airway biopsy to look for Wegener’s, she notices that Hannah appears to be in REM sleep, but with her eyes open while sitting up (these symptoms never seemed to be fully explained). To House, this suggests a movement disorder of some kind. Foreman thinks rabies, though Chase is concerned about allergies. While an allergy test is being administered (ever notice how many of House’s patients only develop problems during testing? My recommendation: never undergo testing by one of House’s team.), large bruising on the abdomen is seen correlating with severe internal bleeding. Foreman reports that blood tests show that Hannah is in acute liver failure, and without a transplant, she’ll be dead within hours. (In terms of the bruising and bleeding, the liver makes blood clotting proteins, so as the liver fails, it stops making these proteins any more and bleeding occurs).

Hannah’s partner Max volunteers donate part of her liver to her since they have the same blood type. House figures that the transplant will give them another thirty-six hours to figure out what’s wrong with Hannah. Thoughts include viral hepatitis, cancer (splenic or ovarian), non-Hodgkin’s Lymphoma, Wilson’s disease, or poisonous mushrooms. Multiple tests are performed to look for these conditions.

The surgeries are successful (though none of the surgical teams are wearing eye protection, a major safety infraction). All the tests come back normal. House decides that Hannah’s immunosuppressant medicine is hiding the underlying condition, so he stops them all (immunosuppressants are used after transplant to prevent rejection of the new organ). Soon Hannah has severe a severe rejection syndrome with a high fever. Her white count is normal, when it was expected to be low, so this tells the team that she has an infection of some sort. The differential includes tularemia, leptospirosis, typhoid, and relapsing fever (typhus). House suspects that the infection is somehow related to the dog, and when he realizes the dog came from the southwest, he examines the patient and quickly finds a buboe (a swollen lymph node infected with the bacteria Yersinia pestis), confirming the diagnosis of bubonic plague. Plague is transmitted by fleas, so House hypothesizes that the plague-carrying fleas which normally affect prairie dogs infested Hannah’s dog, and then jumped to Hannah. With time and strong antibiotics, she’ll be better.

The medicine was fair. No big mistakes — other than the lack of protective eyewear and the bright red blood — but a number of medium-sized errors. No story breakers this week.

The non-medical soap opera content was the highlight of the episode. This week, it all dealt with ethics. First, there was the disagreement between Foreman and Cameron over the ethics of publication. Cameron had prepared a paper on one of their patients and given it to House to review. Foreman also wrote a paper on the same patient well after Cameron did, managed to get House to review it quicker, and got it published first. This incensed Cameron and she accused Foreman of stealing her work, or at least her idea. At the end, she apologizes to Foreman, but he refuses to apologize to her, telling her that he had done nothing he needed to apologize for, and furthermore, they were not friends, only colleagues. Second, there was the ethics of love between Hannah and Max. Hannah is planning on leaving Max, but there was concern that if Max were to find out, she wouldn’t donate part of her liver to Hannah. Cameron wants to tell Max the truth, but House doesn’t want her to. In the end, it turns out that Max knew all along, and is using the guilt of the liver donation to keep Hannah in the relationship. I liked the way that there were no clear winners or right answers in the ethical debates. Nobody was right.

The mystery gets a solid B+, and the solution earns a B+ as well. This overall medical score gets a straightforward B. The non-medical content was the best part of the episode and earns an A.

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Tags: television medicine house plague grand rounds.

The fourth episode of House in a row that features sex as a selling point. Enough already, please!

Melinda Bardach is 16 year-old girl who is deathly allergic to penicillin, bee stings, and peanuts. Thanks to trauma from an automobile accident, she also needed a heart transplant. She lives in a specially prepared clean room, and is not allowed out except to visit the doctor. When friends come to visit, they have to scrub down and wear a mask. Melinda’s boyfriend visits her and she wants a kiss. As he leans down to kiss her, he notices hives on her skin. Within seconds, she is wheezing and having difficulty breathing. angioedema sets in. Her mother rushes in and gives her a shot of epinephrine to stop the anaphylaxis.

By the time Melinda is admitted to House’s service, she has undergone “4 days of work-ups” which were all negative. Looking around Melinda’s room at home, Cameron and Chase notice that one window is unlocked, does not have and alarm, and is conveniently near a tree. They confront her boyfriend who admits he snuck in the night before her attack and that he and Melinda had sex. They test his semen, but Melinda shows no allergies against it. House questions him more closely and discovers that he took a week’s worth of antibiotics — penicillin, he thinks– before visiting her because he didn’t want to get her sick. The team deduces that just enough penicillin molecules were in his semen to set off an allergic reaction the next day. Just as House is ready to discharge Melinda home with a diagnosis of ‘allergic reaction” she goes into pulmonary edema, with sudden onset of wheezing, crackles in the lungs, white frothy sputum, and jugular venous distention.

Tests show that Melinda has developed congestive heart failure (the heart isn’t beating strong enough and fluid is backing up into the lungs). There is question whether this is a separate event from the allergic reaction, or if the two are connected. Cameron suggests a toxin of some kind, but that is ruled out. Other thoughts include an infection, heart disease, or rejection. A CT (apparently of her entire body) was negative, as were blood tests to rule out infection (though they came back way too soon. Negative blood cultures take forty eight hours) and a heart biopsy to rule out rejection. Meanwhile, Melinda has fled from her room. Foreman finds her on a back staircase, wanting to go outside, but too scared to go. As he escorts her back down to her room, he notices a left foot drop, which he refers to as steppage gait, but that’s a neurologist for you. As she is being examined for the foot drop, he also notes muscle fasciculations in her leg and diagnoses her with an ascending paralysis (a paralysis that starts at the extremities and works its way in, rather than the other way around).

Cameron suggests tick paralysis, but this is discarded when House points out that thorough exams showed no bites or ticks. ALS and MS — the usual suspects — are mentioned, as are Guillain-Barre Syndrome, botulism, and the catch-all viral infection. A spinal tap is obtained but is shows no evidence of viral infection. EMG (electomyography) shows increasing weakness in her lower-extremities and Foreman is convinced she has Guillain-Barre (an overactive immune response that causes paralysis). She is started on plasmapheresis, which filters out the offending proteins, but shows no improvement. Clearly depressed, she once again develops trouble breathing. This time her lungs are clear and there is no evidence of any allergic reaction. She is intubated and Foreman informs her parents that the paralysis has spread to her lungs (though presumably he means her breathing muscles, and not the lungs themselves).

Foreman and House agree that the paralysis has spread too fast for Guillain-Barre. Cuddy has taken over the case and ordered a spinal MRI to look for a possible lesion there. The team discusses but quickly dismissed the possibility of a toxin from glue inhalation or pesticides. House now decides the answer must be botulism and figures that the boyfriend smuggled in some food. He pulls his usual extubate-the-patient-so-I-can-question-them-as-they-are-gasping-for-air stunt, but Melinda is adamant that her boyfriend did not bring her any food. She also mentions that he had not been taking penicillin, but instead clindamycin – an antibiotic that she is not allergic to. The team now realizes that all three conditions (the allergy, the heart failure, and the paralysis) must be related – House belatedly decides that Cameron was right all along about the diagnosis: tick paralysis. He deduces that the boyfriend must have accidentally brought the tick in with him and that the team must have missed the tick on exam. As Melinda is sliding into a fatal heart rhythm, House declares that he must find and remove the tick before anything else. As Foreman pumps her full of atropine, House searches her entire (and I mean entire) body and manages to find the tick, lodged in the most unlikely of places (and during the most ridiculous scene in quite a while).

Let’s look at the diagnosis and the three main complaints:

1. Anaphylaxis: There have been cases of anaphylaxis from tick bites, though the time course seems a little off. Anaphylaxis usually kicks in quickly, or at most four hours after an exposure, not a day later — though it is possible that the tick had been wandering around for a while before it decided to settle down and bite. I’d also like to know that if it was an allergy to the tick bite that caused her anaphylaxis, then why didn’t she continue to have the reaction while in the hospital as the tick was still attached.
2. Heart Failure: I’m assuming that the paralysis is what led to the heart failure, though some animal studies have shown that tick venom has a direct affect against heart muscle. While atropine is used as an antidote to some neurotoxins, and it can speed up the heart rate under certain conditions, I think its use as depicted here is quite a stretch. It is not indicated in the treatment of tick paralysis or the routine treatment of heart failure. Speaking of heart failure, I never saw them do anything to treat the failure, and the CT scan is not a good way to evaluate heart failure (echocardiogram with doppler is much better).
3. Ascending paralysis: Right symptoms, but the time course is wrong. The symptoms of tick paralysis are fairly slow, taking several days to progress once they appear, not just a few hours. It usually occurs in people who have ticks that have been attached for 5-7 days, and that seems to fit this case as Melinda underwent “four days” of tests before coming to see House. I will agree that House is absolutely correct in that removing the tick solves the problem.

The soap opera again centered mostly on House and Wilson being roommates. House was cruel, but Wilson got him back in the end. Foreman is becoming the strongest of the junior doctors, standing up to House on several occasions this episode. Finally, for Hawk, who thought that Cameron wasn’t getting her share of the limelight: not only was she correct about the diagnosis, she also got the best zinger of the show in her little crack about Chase’s “staying power.”

The mystery was good, so I give it a B+, but the solution was quite a stretch so earns a C-. The medicine overall gets a C because there were too many holes. The soap opera was slight, but fun, so earns a B+ as well.

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Tags: television medicine house guillain-barre botulism tick paralysis grand rounds.

Another episode of House that starts with sex and ends with a near-death condition. Sure…you want to hear more, but be warned, there are spoilers below!

While involved in some rough sex play, Bob suddenly has difficulty breathing. His tongue swells so much that it cuts off his airway. He’s gasping for air and his lips are beginning to turn blue. His wife calls 911.

When he is examined several days later by Cameron, Bob mentions that he has already seen a variety of doctors who were unable to find the source of his problem; they was referred him to House. The team’s initial differential diagnosis includes food allergy and ALS (amyotrophic lateral sclerosis, better known as “Lou Gehrig’s Disease”). House suspects that there may be something wrong with the lungs and not just the throat. He is right: plethysmography shows decreased lung function and a CT scan of the lungs shows significant scarring.

Foreman diagnosis Bob with interstitial pulmonary fibrosis, but he isn’t sure what the underlying cause of the lung fibrosis is; Bob does not have arthritis or sarcoidosis, and he has not been exposed to any toxins such as asbestos, silica, or coal dust. About this time, Bob develops an intensely itchy red rash on his chest. Foreman suspects lupus while Chase continues to believe that it is a food allergy. House declares that Bob has heavy metal poisoning.

Treatment for lead poisoning — the most common toxic heavy metal — is started but does no good; to appease Chase, allergy testing is started as well. At this point, Bob complains of peripheral neuropathy — a very painful burning sensation in the feet. A short time later he begins having difficulty breathing again. Bob needs intubation, but he is vomiting so much that the team is worried about aspiration. A tracheostomy is performed instead. Additionally, he is now starting to show signs of kidney failure.

House is convinced that Bob’s wife is poisoning him, but he can find no evidence, even when she submits to a search. Meanwhile, things are going from bad to worse for Bob. He suffers a cardiac arrest that requires defibrillation to correct.

Foreman continues to believe that lupus is the cause, but House now suspects that Bob has a post-viral autoimmune reaction (basically, Bob’s body over-reacted to a viral infection and is now producing antibodies that are damaging his own body). He is started on interferon, an immune-system modulator, but it has no effect even at high doses. In a flash of sudden inspiration, House realizes that Bob is indeed being poisoned by his wife with small amounts of gold (actually, gold sodium thiomalate, an older arthritis treatment rarely used in the U.S.) He catches the wife red-handed (or purple handed, as it were) and starts Bob on dimercaprol, the treatment for gold toxicity.

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I’ve really got no big medical complaints with this episode. The gold was actually quite clever. There are some nitpicks, of course (such as starting the defibrillator at 360 joules), but nothing major. I would also have run some tests differently (for example, I’d probably have performed a biopsy of the rash fairly early on), but that’s mostly personal preference.

The soap opera dealt with House and Wilson, who are now sharing an apartment since Wilson’s wife kicked him out. It also involves food and house cleaning.

This episode earns an A for the mystery, and another A for the solution, and yet another A for the medicine overall. The soap opera was minor and average and deserves no more than a C. I’ll give the herpes side plot an A of its own, because that’s an all too common situation that doctors find themselves in (and by that I mean diagnosing someone in an allegedly monogamous relationship with an STD, not getting herpes).

• The previous House review
• A list of all prior House reviews

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Still want more top of the line medical information? Check out this week’s Grand Rounds over at NHS Blog Doctor. Grand Rounds is the weekly collection of the best medical blogging on the ‘net and is well worth your time to check out.

Tags: television medicine house gold heavy metal lupus grand rounds.

A patient and her husband are in the clinic for a rash the wife has, an angry red splotch in the center of the abdomen. It was nothing out of the ordinary: a nickel dermatitis. Basically, she’s allergic to the nickel on the button fly of her jeans. It’s easily treated with avoidance and a topical steroid cream.

Her husband wasn’t so easily convinced. “Are you sure she’s not allergic to her IUD?” he asked.

I told him that he watched too much House.

(And then his wife sweetly informed him that she’s never had an IUD.)

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A young professional in her mid-twenties was in complaining of insomnia. She stated that she had begun having trouble sleeping about two years ago, just after her daughter was born.

“Nobody ever told me that babies cry at night” was her explanation.

I really had nothing to say to that. I just smiled and nodded politely.

Tags: medicine house dermatitis insomnia

This episode of House, “Damned If You Do,” is a repeat of one of the early episodes from last season. My review at the time was fairly brief. I stand by it, but I thought I’d take a second look at the episode, particularly the medicine. As usual, there are some significant spoilers in the review…

House’s final clinic patient of the day is Sister Augustine, a nun complaining of a rash on her hands. He diagnoses her with contact dermatitis and recommends an over-the-counter antihistamine and a topical steroid cream. Shortly after taking the antihistamine, Sister Augustine develops severe wheezing. House gives her a shot of epinephrine; it restores her breathing, but unfortunately it knocks her into cardiac arrest. Epinephrine is the medical name for the hormone adrenalin. Sister Augustine is successfully resuscitated and admitted to the hospital.

The team considers the diagnoses of cellulitis and vasculitis, particularly Churg-Straus Syndrome. Cellulitis is a type of skin infection and vasculitis is an inflammation of the blood vessels. Labs are drawn and Sister Augustine is started on high dose steroid therapy. The tests come back normal but Sister Augustine develops olfactory hallucinations, religious visions, and seizures — signs of brain injury. She is subsequently diagnosed with herpetic encephalitis, an infection of the brain caused by the herpes virus (though the diagnosis is forgotten halfway through the show).

The team next suspects that Sister Augustine has Mixed Connective Tissue Disorder. The usual treatment for this condition is steroids, but since they will also worsen her encephalitis, the steroids cannot be used. Steroids work by dampening the immune system. This is good for connective tissue diseases when the body is under attack by its own immune system; however, slowing down the immune system is bad idea during infections. House suggests placing Sister Augustine in a hyperbaric oxygen chamber. Foreman believes the idea is dangerous and complains to Cuddy, who takes House off the case.

Cuddy takes over and, frankly, does a horrible job. She focuses only on symptoms and doesn’t even bother to look at causes. She’s dangerous too, putting the patient on a NSAID (a Non-Steroidal Anti-Inflammatory Drug — the same class of drugs as Motrin, Advil and Aleve) despite the fact that the patient is in kidney failure and liver failure — which this class of drug can cause or worsen.

After talking to the Mother Superior, House learns that Sister Augustine lived a fairly wild life before becoming a nun. He also realizes that she’s been drinking figwort tea. According to him, combining figwort tea and epinephrine will lead to a cardiac arrest (though I can find no evidence or documentation of this anywhere).

House resumes care of Sister Augustine. He is convinced that she is suffering from some kind of severe allergic reaction. She is moved to a special non-allergenic room, but she still goes into anaphylactic shock. Belatedly, House realizes that she must be allergic to something within her, and a CT scan reveals an old copper IUD. It turns out that she was allergic to copper and the recent exposure to some new copper pans kicked the allergy into overdrive.

The medicine in this episode was pretty good excepting the problems I mentioned above. I will also point out that connective tissue diseases and vasculitis cannot always be ruled in or out by lab tests alone. This is one of the few episodes — and quite possibly the only one — where it take three separate diagnoses to explain the patient’s symptoms.

This was an early episode and the soap opera elements were just coming together. The beginnings of Cameron’s infatuation with House can be seen, as well as the start of the House versus Foreman ego battles.

This episode earns a B+ for the mystery, and an A for the solution; the medicine deserves a B overall (marked down for Cuddy’s ham handedness). The soap opera also earns a B. There’s not much, but what is there is good.

• Previous House reviews

I don’t do a great deal of link-blogging, but as I was sitting around donating blood yesterday, I decided it would be a good time to look once again upon the wonderful world of comic books and …well…blood. Here’s a selection of fun reads, from blood being responsible for super powers, to blood in comic book ink (and the inevitable demonic possession that follows), to Superman and “alternative medicine,” and finally a look at what our government talks about in offical meetings.

• I know I’ve posted this one before, but it’s too good to pass up. Is Superman’s blood responsible for every super-hero ever? This author thinks so.
• In a similar vein, here’s an article looking at Clark “Hugo” Kent and Superboy and Supergirl. It tries to tie together Siegel and Shuster Superman, Wylie’s Gladiator and much of the Silver Age superbooks.
• From Snopes, is the blood of the band KISS really mixed in with the ink in their first comic book? (No mention of the late Mark Gruenwald and the Squadron Supreme TPB at Snopes, though here it is mentioned in the sidebar of an HBO article on Six Feet Under). According to the conspiracy-minded Jack Chick wannabe Last Trumpet Newsletter, these comics are occult and pure evil!
  

  This nation has developed an insatiable appetite for the occult. One example is the popular demand for a special edition comic book printed with ink that was mixed with the cremated ashes of the author, Mark Gruenwald. The Canton Company made the special ink for the printing of “Squadron Supreme.” (12) This is reminiscent of the 1978 comic book published by Marvel Comics printed with ink mixed with a vial of blood from each member of the rock band, KISS. (13) The name KISS is an acronym for “Kings In Satanic Service.” These comics are read by millions of young people, and the special ink mixed with the ashes of cremation or the blood of the living, devil possessed people attracts evil spirits and gives them the right to stay in the homes of those who buy the books.

• Here’s an article from a homeopath claiming to have cured Superman’s “allergy” to kryptonite. (Makes sense: Superman is an imaginary character and the benefits of homeopathy are all purely imaginary)
• A transcript from a Health and Human Services meeting on “Blood Safety and Availability” where they discuss the poor transfusion techniques at Metropolis Hospital.
  

  Well, as part of my due diligence, I pursued to see what other hospitals in the United States were doing as well. And I came across this photograph in the newspapers which showed Superman receiving a blood transfusion. One of my colleagues, upon seeing this, said, “Well, there’s your answer. Superman doesn’t get leuko-reduced blood. There’s no filter in the line.”

  I was chagrined. So I actually called the Metropolis blood center, spoke to the director, my good friend, Jarriel [ph], and I asked him about this, and he said not to worry, pre-storage leukoreduction.

  [Laughter.]

  DR. SNYDER: So that clearly explains why there is no filter. But ever mindful of the FDA guidance, 606.122, paragraph B, to use a filter in the administration equipment, if you look closely, there are 270 micron filters right over there.

  Lest you think, however, that I am biased by my friendship, let me point this out, that this photograph also shows Lois Lane donating double the usual amount of blood and her saying that she’d gladly give it all. She doesn’t want to go on living. So I bring to the FDA’s attention that the Metropolis blood bank may have some conflicts as far as the validity of the donor screening and also their SOP for blood donations.

Update (14 Sep 05 0830): Broken links fixed.

As usual, Polite Dissent was a frequent stop for people searching for Hawk and Dove, Bwana Beast, Dave Trampier and Kim Possible. Some of the more interesting searches this month (with my comments in italics):

• anxious vigilante – The worst type of vigilante. You never know if they’re going to shoot the criminal or a passerby.
• ornithopters fiction – I know Michael Moorcock used them in his writings, especially in the Hawkmoon series.
• hawk and dove homosexual comic – You do realize that the only time Hawk and Dove haven’t been siblings, they’ve been boy/girl, right? You’re either misinformed, or need some serious help.
• medical term for tricycle antidepressants – We tend to call them tricyclic antidepressants, not tricycle. Try searching for that.
• medical terminology for poison ivy – It’s a type IV hypersensitivity reaction (a type of allergy). Old — but still fashionable — terms for poison ivy include rhus dermatitis and toxicoderma dermatitis (from it’s scientific name).
• best anime openings – I like Witch Hunter Robin, Gunsmith Cats, Martian Successor Nadesico and Full Metal Panic best, though I still have a soft spot for Starblazers, with the asteroids circling the ship while the music starts.
• Medical show with Ben Casey – Umm…how about Ben Casey?
• med school disease – This occurs when a medical student is convinced that they have whatever disease they’re currently studying in class.
• the gift of the magi climax – She gives him a watch fob and he gives her a set of brushes.
• superman for the animals – Please, let’s never mention this again.
• orginal bat-girl – Betty Kane, the niece of Kathy Kane (Batwoman). She’s been ret-conned as Bette Kane, Flamebird.

Brat Pack
Rick Veitch, writer and artist

The Midnight Mink has a secret: he has a healing factor with amazing regenerative capabilities. He took a round of bullets point blank and lived to tell the tale. He didn’t come by these abilities naturally, instead it was a gift from True-Man:

…one day I got careless and [True-Man] had to perform immediate hyper-speed surgery to save my life.
That’s when he noticed I was H.I.V. positive
True-Man went away soon after that. But he left me with a parting gift…a transfusion of his own blood.
He knew his hyper-powered antibodies would make my own weakening immune system almost as strong as his own.

Now that the Mink’s sidekick, the latest Chippy, has learned the secret, he shares the healing factor with him by a transfusion.

As comic book transfusions go, this one is fairly low key and makes sense — in a comic-book science way. My main nitpick would be gravity. There’s not enough blood pressure in the Mink’s arm (even if he used an artery instead of a vein) to push the blood to the top of the IV stand. Remember that when you give blood, the collecting bag is hanging lower than you. The Mink needs to be closer with the blood transfusing directly into Chippy, or he could be above with his blood running down, or an already collected bag of blood could be transfused.

I also have some questions regarding the Mink’s description of his healing abilities. I can see how “hyper-powered antibodies” would be able to prevent disease and infections, but a lead bullet is not an infection. I’m not sure how these antibodies would be able to heal such things as punctured lungs, ruptured muscles, and so on. Antibodies do not play a role in this kind of rebuilding. Additionally, antibodies have a limited lifespan (about 3 months) and need a variety of specialized white blood cells (B-cells, T-cells, APCs and so on) around to consistently produce them. I suspect that Midnight Mink’s understanding of the whole situation is limited and the transfusion supplied more than antibodies, probably a beneficial virus or some form of modified DNA.

It also apparently only takes a small amount of the blood to pass on the healing factor. Chippy is able to transmit it to the other sidekicks with just a sip or two of his blood in a later scene of the book. This lacks the forced intimacy of a transfusion scene, but it does add in a Last Supper-like “this is my blood” connotation.

Note that I used the Brat Pack trade paperback for this review; it has some differences from the original issues.
Thanks to Jog for reminding of the transfusion scene in Brat Pack. I also note that Brat Pack is copyright 1991. This makes Midnight Mink one of the earlest H.I.V. positive superheroes, if not the first.

A few words of wisdom regarding rashes. Do NOT put any of the following on a rash unless explicity told to do so by a physician (or Physicans Assistant or Nurse practioner — I’m open minded):

Bleach
Should be a no-brainer, but would I be mentioning it if I hadn’t seen somebody do it?

Butter (or Margarine)
I don’t care what your dear old Grandmother told you, do not put butter on a rash. There’s a good chance it could make things worse. Plus you’ll get grease marks all over your comics and computer.

Neosporin
This product only has a very limited use. It should not be used as a general spread for any rash. It contains neomycin, which can be very irritating and even allergy-inducing. Use with caution. (Personally, I don’t use it at all. I don’t think it accomplishes anything plain old soap and water can’t).

Alcohol
I’m specifically talking about rubbing alcohol here, though you really shouldn’t apply any alcohol to your body except in rare situations. Rubbing alcohol is very drying and irritating so often makes rashes worse.

Another Tuesday, another episode of House. It was a good episode, but it just reinforced some of my complaints about the first episode.

(Yar, there be Spoilers below!)

Once again, the final diagnosis was unorthodox, but clever. Just like in the first episode, the team doesn’t so much as deduce the correct diagnoses as much as stumble toward it like a drunken sailor staggering down the street. It’s multiple sclerosis! No, it’s neurosyphillis! No wait, it’s subacute sclerosis panencephalitis! There doesn’t seem to be any rhyme or reason to their diagnostic strategy; they just jump from one convenient explanation to another.

The whole adoption issue and sub-plot was just nothing but a smokescreen. Despite what Dr. House shouted, it did not affect diagnosis. House had never asked the mother about her immunization status when he thought she was the patient’s natural mother, so why should it suddenly matter when it turns out the patient is adopted? It just gives the writers another excuse to show Dr. House’s “brilliance” and “non-conformity” (and lack of ethics).

I realize it’s only been two episodes, but I’m starting to notice a pattern: due to some unforeseen complication, the ordinary diagnostic techniques won’t work and the team has to use some clever and unconventional means of diagnosis. In the first episode, the patient had a sudden (and suspiciously convenient) gadolinium allergy, so an MRI couldn’t be used. The doctors then had to x-ray her leg looking for glow-in-the-dark worms instead. In this episode, the patient’s spinal fluid couldn’t be tested because of the treatment they’d already given him (which makes little sense), so they had to get a tissue sample from the back of his eye.

Once again, the hospital seems strangely understaffed as the young gun physicians end up running all the tests themselves.

I don’t know if I missed it in the first episode, but apparently each of the young guns is some sort of specialist. We find out this episode that Omar Epps character is a neurologist (which is lucky, since both of the first two cases have been neurological cases).

Now, don’t think I don’t like the show. It’s very enjoyable and better than 90% of what’s on television. Hugh Laurie is great as Dr. House, and the characters of Omar Epps and Sean Patrick Leonard are growing on me. I just have high expectations for a show that bills itself on cleverness and zebras.

It’s that time of the month again. Time to see what bizarre searches led people across this wide old internet to Polite Dissent:

The most common searches were Bwana Beast, She-Hulk, Kim Possible (and her various friends and enemies), Pica (especially ice, laundry starch and cardboard), and Dungeons and Dragons adeventures (particularly The Forgotten Temple of Tharzidun). I think I hit a nerve talking about Dave Trampier’s comic strip Wormy because that was a big hit as well. Sadly, I had only one search this month looking for Zatanna naked, and none looking for her in culottes.

rarest disease I’d stick with Kuru, the brain disease transmitted by eating other people’s brains.

obsequious spleen disorder Exactly how can a spleen be obsequious?

useful sentence for conversation in coffee shop Would you like a biscotti with that?

blog gorilla comic library You’re probably looking for Yet Another Comics Blog and his monkey cover Sundays.

empty narcotic bottles on e-bay Every month somebody is searching for this. Why?

correspondance school appliance repair This is a comic book and medical blog; Sally Struthers is not mentioned anywhere.

heimlich maneuver talespin “Baloo, help! I’m choking!”

best neurosurgeon 2004 I’m not sure the best neurosurgeon of 2004 is, but I can tell you that Thomas Elliot is the “best neurosurgeon in the world!” (And remember, the phrase “best neurosurgeon in the world” is © and ™ 2004 by Polite Dissent)

Finally, here are the searches I can’t even begin to explain:

lettuce sedation iceberg allergy

non-cartoon bacteria medium

when will you humans learn feelings

The areas where I have seen the biggest influence of prescription drug advertisements has been in arthritis pain medications and stomach/heartburn medications. Both of these diagnoses cause significant pain, so it’s easy to understand why patients would want quick relief and why advertisements would catch their eye. In both these cases, however, there are over-the-counter (OTC) or generic drugs that work just as well, if not better. These are also some very expensive drugs. Insurance companies provide limited formularies, with only one or two of these expensive drugs on them, and even then you have to jump through hoops to prescribe them. I have to routinely tell patients who want a particular arthritis pain medication that they must first have tried, and failed, two other pain medications before they can get the ones they want. That’s two months of waiting, and most patients are very unhappy with that.

I have a fair number of patients who come in seeking allergy relief after seeing ads. Again, prescription allergy medications are expensive drugs. In this case though, there are no really good OTC or generic equivalents. There are still insurance restrictions, but not as strict as those for arthritis and stomach medications.

Occasionally, I’ll see a patient who comes in inquiring about an anti-depressant after seeing advertisements. This is the area where I actually see some benefit from ads. Many people have depression, but don’t realize they have it, aren’t sure it can be treated, or are embarrassed to admit that they are depressed. The ads help reassure patients and remove some of the stigma of being on anti-depressants.

Finally, I have seen absolutely no changes in my practice due to advertisements for high blood pressure or cholesterol medications. This makes perfect sense. Neither high blood pressure of high cholesterol have specific symptoms, so patient are not going to go out of their way to seek treatment.

In a given week, about 10-15% of my patients are clearly influenced by advertisements, while at least another 30-50% show are familiar with the ads. I generally dislike the idea of having prescription drugs advertised nationally, with the possible exception of anti-depressants. However, I prefer well-regulated prescription drug advertisements to the misleading and sometimes dangerous advertisements and infomercials for “nutritional supplements”, alternative “medications” and diet aids. But that is a rant for another day.