Polite Dissent

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The SHIELD #8
Eric Trautman, writer
Cliff Richards, artist.

The SHIELD is surprised to find that one of his enemies, the mind controlling Brain Emperor, has been assigned to his team. He is understandably upset and wondering if mind control is involved. His computerized suit reassures him: “Confirmed: No hostile action detected. Baseline EKG readings normal.”

I’m not sure who the SHIELD’s suit is referring to — are the “baseline EKGs” normal in the Brain Emperor or in the rest of the military staff?

It does strike me as unusual that an EKG — a heart test — is being used to detect mental influence; wouldn’t an EEG — a brain test — make more sense? (On the other hand, it does open up some interesting plot possibilities. For instance, if using mind control causes heart damage, then how far are you willing to push it?)

A nitpick: The term “baseline EKG” has a specific meaning, and it doesn’t fit here. When a patient is diagnosed with conditions that have an increased chance of heart disease (high blood pressure or diabetes, for instance), we will often obtain an initial EKG. This is their “baseline EKG” that we keep on file to compare against any EKGs obtained later to see if anything has changed. So someone having a normal baseline EKG just tells us that when the EKG was originally obtained, everything was fine. It tells us nothing about the current situation.

After a big fight, the SHIELD suit’s healing mechanisms kick in: “Nanotech regrowth engaged. Priority reconstruction: bronchial puncture and tearing, shattered third and fifth vertebrosternal ribs.

This is correct, it’s just too wordy. The vertobrosternal ribs are the first seven pairs of ribs, also known as “true ribs”, that start at the spinal column and wrap around to the breastbone (sternum). The remaining five pairs of ribs are known as the false ribs because they don’t attach to the breastbone.

If you haven’t figured this out by now, in medicine we like to convey as much useful information as possible in as few words as possible. This is especially true in emergency and trauma situations. That’s why we like abbreviations and acronyms so much.
There is nothing in the phrase “shattered third and fifth veterbrosternal ribs” that can’t be conveyed simpler by just saying “shattered third and fifth ribs.” (Though which ribs was fractured –the left or right — would be useful to know.)

I’d say this one can probably be blamed on whatever computer techie programmed the suit. In terms of medical programs, I’ve noticed you can tell which ones were written by doctors (good medicine, sloppy code) and by programmers (sloppy medicine, good code). I’m still looking for a program that does both well.

The Brave and the Bold #31 “Small Problems”
J. Michael Straczynski, writer
Chad Hardin and Justiniano, pencilers

The Atom is called to Arkham Asylum to treat a neurological problem the Joker is having. He has to shrink down to microscopic size, enter the brain, and release an “experimental chemical” at a specific location to cure the Joker.

There are many, many problems with this comic. I’m all for Fantastic Voyage homages, but it is obvious that Straczynski has no understanding of how the brain or nervous system actually functions. A twelve year old with access to Wikipedia and five minutes to spare could write a more accurate — and no less engaging — story.

The main stumbling block is Straczynski’s misunderstanding of synapses — the junctions between nerve cells*, where one cell passes a signal to the second cell. These synapses can be either chemical (a message molecule known as a neurotransmitter carries the impulse from the first cell to the second cell), or electrical (the two cells are connected by channels which allow an electrical signal — ions, really — to be passed from the first cell to the second cell).

I’ll just touch on a few of the bigger errors here:

What the doctor here is describing is not particularly rare at all. When too many synapses fire off, you have a seizure. If it involves part of the brain, it’s a partial seizure; if it involves most of the brain, it’s a generalized seizure. If the seizures happen repeatedly, then it’s considered epilepsy. If it is a seizure that cannot be stopped, then it is called status epilepticus, and yes, it can lead to brain damage and death (but it’s not rare: 42,000 deaths a year). • If the Joker really were in status, he’s be dead long before the Atom ever got there.

This is some horrible, horrible technobabble. I know everyone uses “the brain = a computer” metaphor, but it’s just that: a metaphor; a figure of speech. The brain is not really a computer — it is orders of magnitude more complex and you can’t “reboot” it. For one thing, I’d want my brainstem to keep working no matter what, since it controls such things as the heartbeat and breathing. • “Synaptic array at the microscopic level” is redundant. All human synapses are microscopic.

Straczynski seems to think that all synapses are electrical in nature, but that is not true — in fact, chemical synapses are much more numerous; electrical synapses only show up in certain pathways where speed is important — reflexes, for instance. He spends most of the issue confusing the two types of synapses. “Synaptic gaps” occur in chemical synapses; electrical synapses are tied together by ion channels. Chemical synapses are involved in the higher processes, like memory. Electrical synapses transmit ions from one nerve cell to another through channels in the cell membrane — there is no “electrical pulse” or lightning bolts (as drawn in the comic) between the nerves. The rest is just more technobabble.

For a better “The Atom in somebody’s brain” story, I recommend The Brave and the Bold (original series) #115, where the Atom controls a brain-dead Batman to solve his murder.

*There are also synapses between nerve cells and other cells, such as between a nerve cell and a muscle cell.

This episode was better than last week’s pathos-fest, but it was still lacking in the medicine department.

Valerie is a 27 year-old ruthless business woman who experiences the sudden onset of severe bilateral ear pain. She is admitted to House’s team, even though he finds her case uninteresting, because she is “hot” and yet has an ugly husband. Chase suggests that due to a recent dietary change, Valerie may have a vitamin deficiency which is causing her symptoms. House thinks that her change in diet may have boosted her already elevated cholesterol, leading to blocked arteries, heart damage, and an arrhythmia (abnormal heart rhythm) which she experiences as ear pain. Testing shows no evidence of blocked arteries, but it does confirm an arrhythmia. The team plans to start her on unspecified “cardiac medications.”

An ex-coworker of Valerie’s appears in her room, drunk, and accuses her of having an affair with him and later poisoning him to cause him to lose his job. She denies these accusations and security escorts the man out. The male members of the team jump to her defense, but Thirteen thinks that Valerie is up to something. When the team discussed the situation with House, he suggests that she may have been poisoned with thyroid medication, which would rev-up her heart and cause the arrhythmia. House and Foreman want her started on beta-blockers (to block the effects of the thyroid medication), but Thirteen sneaks her off to the MRI suite. Her testing reveals that Valerie has no emotions and is by definition a psychopath. Confronted later, Valerie admits to everything Thirteen suspects. All that her co-worker said is true — she slept with him and then poisoned him. She also admits she only married her husband for his trust fund.

Taking both the heart and brain symptoms into account, the new differential diagnosis consists tertiary syphilis (late stage syphilis where mental symptoms are common), Wilson’s disease (a disease of copper metabolism), and Hashimoto’s thyroiditis (autoimmune inflammation of the thyroid gland). The first seems the most likely, so they start Valerie on penicillin. There is a heated discussion between Valerie and Thirteen, and when Thirteen reaches to turn over Valerie’s arm, she breaks it. Further testing reveals elevated BUN (blood urea nitrogen) and creatinine levels which suggest kidney failure, which would explain the brittle and easily-broken bones.

House now feels that the Valerie’s psychopathy is something she was born with, and not a symptom of her condition. Focusing on the heart and kidney symptoms, Foreman suggests that she has paraneoplastic syndrome, likely from a lymphoma. House orders full body radiation therapy. Thirteen wants to run some tests first, but Foreman shoots her down.

There are more confrontations between Valerie and Thirteen, with Thirteen’s “innocent” questions lead Valerie’s husband to realize she’s was having an affair, and Valerie reporting her to the medical board. Eventually, Thirteen is removed from direct patient contact with Valerie, but Cuddy explains is it because Thirteen does not deserve to have Valerie inflicted upon her.

Valerie starts bleeding heavily from her mouth due to esophageal varices (enlarged, bleeding esophageal veins related to liver disease). She is taken to the operating room for a TIPS procedure (transjugular intrahepatic portosystemic shunt) — placement of a stent which bypasses the liver, relieving the elevated blood pressure in the liver which lead to the varices. This new symptom causes the team to reevaluate their diagnosis, and this time they consider and discard amyloidosis and alpha-1 antitrypsin deficiency before settling on primary hepatic fibrosis (fibrosis of the liver not due to another disease). She is started on steroids and a search begins for a liver donor for transplant. Thirteen talks to Valerie’s sister and learns that she wasn’t always a psychopath — that started during her teen years. This suggests that the psychopathy is a symptom of her condition, and not something that can be overlooked. Thirteen and House realize that she must have Wilson’s disease, which is confirmed by looking at her fingernails which are blue. She is started on chelation therapy to remove the excess copper. By the end of the episode it seems to be working

Those of you who read comic books will know what I mean when I say that the medicine of this episode was the television equivalent of a Mark Millar comic: a bunch of dramatic set pieces connected by sketchy plotting and poor logic. Sudden ear pain (hand waving) It’s her heart! (hand waving) Oh no, kidney failure! (hand waving) It’s cancer! (hand waving) Now it’s liver failure (hand waving) Wilson’s disease and presto! Iit’s cured, and now the world is safe for democracy.

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

You do not treat a patient for cancer — be it radiation therapy or chemotherapy — without knowing what sort of cancer it is first. Different cancers have different treatments. Even if it is a B-Cell Lymphoma, there are over a dozen different cancers of that type, and only some are treated with radiation therapy. This seems to be a recurrent mistake this year.

Her kidney failure is so bad that her bones break that easily and she’s stopped producing urine and nobody noticed?
There’s no way it took that long before they checked her BUN/Creatinine. They would have been checked before running any cardiac artery testing to make sure her kidney could handle the dye.
Similar arguments for no one noticing her chronic liver disease bad enough to cause bleeding varices.

Wilson’s disease should have shown up on the MRI. You know, the one they used to dismiss the diagnosis of amyloidosis.

She sure improved from her fifteen years of Wilson’s disease improbably fast, especially her psychiatric symptoms.

A paraphrase:
Thirteen: If she has Wilson’s, why doesn’t she have Kayser-Fleischer rings?
House: Notice how I avoid answering — or even acknowledging — your question by distracting you with another symptom. Aren’t I (and by extension, the writers) clever?
(House could have just said that KF rings only occur in 2/3 of the patients with Wilson’s. Blue nails [azure lunula] are certainly seen in Wilson’s, but less commonly than KF rings).

Technically, Broca’s area is only on one side of the brain, it is not bilateral.

I suspect the fingernail polish under the pulse-ox (oxygen monitor) had already been wiped off – the monitors work a lot better that way.

The team never “ruled out” Wilson’s, they just focused on the tertiary syphilis instead.

The medical mystery was modestly interesting, but quickly forgotten and ear-pain was never again mentioned after the seven minute mark. It deserves a B. The final solution was a bit of a stretch, but actually fit fairly well (especially if you ignore the whole “chronic” aspect of the disease). It also earns a B. Overall, the medicine was spotty, with the team missing things an intern would have noticed. I give it a B-. The soap opera was light, but generally well done. I thought Olivia Wilde held up her end better than expected, but I’m surprised House never ran any sort of background check on his classmate. I give the soap opera a B.

The House Challenge scores have been posted here.

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

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

Betsy Crane’s friend and fellow nurse Diane has met and fallen in love with a Jeff, a widower with a young daughter. He saved her from drowning a few weeks before and she has fallen head over heels in love with him.

One day though, Jeff is uncharacteristically brusque to her and Betsy when encountering them on the street. The two nurses head over to Jeff’s house to figure out what is wrong. Jeff is angry that Diane has appeared on his doorstep, but it doesn’t stop him from complaining of a severe headache and eyes that are very sensitive to light. He also suffers a seizure while Diane is pleading with him. Meanwhile, Betsy is talking to Jeff’s young daughter, who mentions that her dog Shag has been hiding from her lately and doesn’t want to play. She also mentions that her father won’t take her swimming anymore because he is afraid of the water. Betsy puts two and two together and realizes that Jeff has rabies, and that he must have gotten from the dog Shag.

Betsy calls her boss Dr. Kiel and he rushes an ambulance out to collect Jeff and admit him to the hospital. He is given daily rabies injections and suffers “sleepless nights and momentary spasms” but “Dr. Kiel and Betsy were always there giving their medical skill and tireless sympathy.” Three weeks later, Jeff is released from the hospital, completely cured, and he and Diane (and Jeff’s daughter and her new dog, Little Shaggy) live happily ever after.

Even by the low standards of a fifty-year old romance comic, this is a horrible and misleading story medically:

Tags: comics medicine rabies nurse dog

Almost entirely a Wilson character episode, so the medicine was fairly straightforward, if surprisingly sloppy

Wilson is out hunting turkeys with Tucker, a friend who he helped defeat leukemia five years earlier. Tucker nearly shoots Wilson when his left arm becomes suddenly numb and paralyzed. Wilson has Tucker brought to the Princeton Plainsboro Hospital emergency room for evaluation. A head CT is negative, and the blood count is normal, which tells Wilson that Tucker has not had a recurrence of his cancer. Noticing a fever blister on the lip of Tucker’s girlfriend, Wilson diagnoses him with tranverse myelitis (inflammation of the spinal cord, it can have many causes, in this case the Herpes simplex virus passed from the fever blister). He admits him to the hospital for treatment with acyclovir (an antiviral drug). House chides Wilson for his diagnosis, telling him that Tucker has cancer. Wilson disagrees and they end up betting $100 on the final diagnosis.

Paying a visit to Tucker a little later, Wilson discovers that he now complains of tingling in his left foot in addition to the continuing numbness and paralysis of his left arm. Wilson sticks with his diagnosis of transverse myelitis, but adds a second antiviral — Ribavirin — to the therapy. There is no improvement, and in the meantime Tucker has developed a nasty cough that eventually devolves into a respiratory arrest (which he survives, or it would have been a very short episode).

Perplexed, Wilson enlists House’s team in reviewing the case. Cancer is suggested, as is a subdural hematoma (bleeding around the brain), bacterial infection, or fungal infection. Wilson agrees with the fungal infection, and suspects that Tucker has aspergillosis (infection by the Aspergillus fungus) including fungal balls (exactly what they sound like) in the lungs and spine. He declares that Tucker is too sick for tests and rushes him into surgery. Chase sees no Aspergillus, but instead finds “global lung damage” suggesting PCP (Pneumocystis carinii pneumonia, a fungal infection of the lungs).

House is watching the surgery beside Wilson, and points out that a PCP infection means that Tucker must have a weakened immune system (since healthy immune systems can easily defeat the Pneumocystis carinii). He states that Tucker must have HIV (the virus that causes AIDS), acquired SCID (Severe Combine Immune Deficiency), or cancer. He suggests that Wilson test for all three.

Sure enough, this round of testing shows cancer — more specifically ALL (Acute Lymphocytic Leukemia, also known as Acute Lymphoblastic Leukemia). This is not a recurrence of Tucker’s original leukemia, but a different one, possibly caused by the chemotherapy required to treat the initial cancer. ALL is fairly treatable, so Wilson starts Tucker on chemotherapy. Twenty-four hours later, there is no change in his condition, and Tucker is concerned he may be in the 10% of ALL cases that Wilson says do not respond to therapy. Wilson decides to double the dose of chemotherapy. It works, more or less. The high dose chemotherapy knocks out the ALL, but it also severely damages Tucker’s liver (the yellow eyes were a sign of jaundice). In fact, the liver damage is so bad that Tucker will die in twenty-four hours if not given a transplant. When it becomes apparent that no transplant is available, Tucker asks Wilson to donate part of his liver to him (he know that they have the same blood type). Wilson thinks on it, and drinks on it, but eventually acquiesces and Tucker receives part of his liver. After the operation, both are doing well and expected to recover fully.

House’s first patient had Popcorn Lung, and diverticulitis (from the popcorn kernels). The second, apparently, had a screw in his lung.

No deal-breaker errors this week, but worse than the last couple of episodes. Some real sloppiness in writing/editing/continuity as well. As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

Wilson is being generous with his ALL prognosis of 90%. The remission rate of ALL in children is 95%. In adults, it is 60-80%, with patient have CNS disease (which Tucker does) having a worse prognosis.
Chemotherapy cures leukemia completely in twenty-four hours? Nonsense. That’s too soon to tell if it’s working at all. Best case scenario is usually remission in 4-6 weeks.

There is no surgeon — even Chase — who would operate on Tucker without at least getting a CT first to show where the suspected fungal ball is. You don’t just slice up the lung indiscriminately. If there were a fungal ball, it would have shown up on the CT, as would PCP severe enough to cause a respiratory arrest.

By my understanding, SCID is currently defined to be a genetic disease, not one acquired later in life. There are acquired immune deficiencies, some severe (most notably HIV), but they are not “SCID.”

I’m surprised none of Wilson’s original blood work showed the cells associated with ALL.

Not my area of expertise or interest, but would a patient with a history of two cancers (though admittedly, no liver cancer or liver metastases) be placed that high on the transplant list?

Left arm or right arm? The episode description and House referred to right arm paralysis, yet the patient was clearly paralyzed in the left arm. Wilson later mention left arm. This is just sloppy.

“PCP Pneumonia” is redundant. The second P stands for “Pneumonia.”

A real nit-pick here, but by the time a patient has PCP, it is considered AIDS, no longer just an HIV infection.

I enjoyed the scenes with Wilson and his other patients.

The medical mystery was routine (as far as House episodes go), but well constructed. I give it a B. The final solution was fairly obvious, but entirely logical: B+. Overall, the medicine was OK, but way too sloppy, and gets marked down to a B-. The soap opera was good, though I would have liked to see a little more of the team. B+.

The House Challenge scores have been posted here.

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A so-so mystery, but an interesting patient on this week’s episode of House.

James Sidas was a brilliant physics prodigy who quit the field twelve years ago and now works as a deliveryman. While he is delivering some books one day, he develops a hand tremor and some confusion. He is admitted to House’s team at Princeton-Plainsboro Hospital, with the presenting complaints of ataxia (loss of coordination), anemia, and a mild cough. A CT scan was negative, as was a screen for toxin screen. The team’s initial differential diagnosis consists of West Nile Virus, hyperbilirubinemia (high bilirubin levels in the blood), meningitis, sickle cell anemia, or TTP (thrombotic thrombocytopenic purpura). The last one seems the most likely so House has his team check a blood smear and AdamTS13 antibodies. The blood smear shows schistocytes (fragmented red blood cells), a sign of TTP, so they decide to begin treatment. Usually, plasmapheresis is treatment of choice, but James is allergic to one of the components of the procedure, so instead they perform a splenectomy — a removal of his spleen. The surgery goes well, but while Chase is examining him afterward, James begins to show symptoms of a stroke. He is rushed to the cath lab, where the clot in the brain is removed by a special catheter, “blood flow is restored,” and there is no permanent brain damage.

The fact that James suffered a stroke after his spleen was removed suggests that he did not have TTP. The differential now consists of CNS vasculitis (inflammation of the blood vessels in the brain), DIC (disseminated intravascular coagulation), acquired pancytopenia (low white cells, red cells, and platelets), or a toxin exposure. The team reasons that the basic toxin screen only tests for a few toxins, and they need to test for more. Chase and Taub are sent to search James’s apartment, while Thirteen and Foreman run an expanded toxicity screen. The apartment shows signs of mice (and Taub suggests James may have Leptospirosis), and a hidden bottle of booze.

The team now suspects that James has liver failure, probably due to alcohol abuse. When confronted, James admits to having a shot of vodka each day after work, but denies being an alcoholic. The team proceeds with a liver biopsy, which is normal. The liver function tests show a slightly elevated albumin, but are otherwise normal. Thirteen now deduces that James has renal (kidney) failure, not liver failure. The reasons for the kidney failure could be rhabdomyolysis (muscle damage), multiple myeloma (cancer of the blood forming cells), polycystic kidney disease, or Goodpasture’s Syndrome (an autoimmune disease that affects the kidneys and lungs). Goodpasture’s seems the most likely, so James is started on unnamed “immunosuppresant drugs” and dialysis. After a Eureka! moment in a conversation with Wilson, House realizes that James has been abusing dextromethorphan (DXM, also known as the DM in “Robitussin DM”). He has been taking it to suppress his intelligence, and taking the alcohol along with it to make it work better. The chronic abuse of the drug has caused his symptoms.

With an aggressive regimen, the drug is cleared from James’s system and his natural intelligence once again emerges. Due to his brilliance, he finds it impossible to relate to his wife anymore, and she herself realizes that he is no longer “the man she married.” While Foreman is trying to explain the situation to James’s wife, he begins to complain that he can’t feel his legs. Foreman evaluates and finds that James has no feeling in his legs at all. The team half-heartedly throws out some ideas including vitamin B12 deficiency, bone marrow malignancy (i.e. cancer of the bone marrow), and lupus, but none of them fit well. House talks to James who admits he had been abusing the dextromethorphan because, while he was intelligent, he was extremely unhappy. He tried to commit suicide once by jumping off of a tall building, but he survived, just busting some ribs. It was while he was in the hospital recovering from these injuries that he was given some narcotic pain medication, and he enjoyed the way it made him feel dumb. After discharge, he sought out the dextromethorphan because it made him feel the same way. Hearing about the history of broken ribs, House realizes that in the suicide attempt, James injured his spleen, causing it to split into multiple smaller (accessory) spleens. Chase thought he removed the spleen, but he removed only one and James still has several more. His ultimate diagnosis is the same one he started with: TTP. Once the rest of the spleens are removed, his TTP will be under better control. He decides to go back on the dextromethorphan though because he’d rather be dumb and happy than intelligent and alone.

For the second week in a row, There were no major errors that jumped out at me in tonight’s episode. The team did their usual combination overlooking certain findings and overtesting/undertesting (diagnosing renal failure without checking renal labs, for instance). Once again, that’s not to say I have no complaints…As usual, minor complaints are in blue, nit-picking ones in green:

Surely before Chase operated on James, he got an abdominal CT scan to double check the anatomy, and surely he would have seen at least one extra spleen (or unexplained mass) on the scan.

If James’s problem had been due to the DXM abuse, which they said caused brain damage, then clearing the drug from his system would not have returned him to his baseline but would have left behind some permanent damage.

Liver biopsy is not performed that early in someone with liver failure. There is much you can discover with labs and CTs/ultrasounds before you go plunging a needle into the liver of someone who is low on platelets.

Did James have accessory spleens or splenosis? It sounds more like the latter to me, but this is not my area of expertise.

The “Otis Campbell” mnemonic is for seizures, not strokes.

I’m not an expert on street drugs, as shown in my review a few weeks ago, but the affects of DMX that House and James describe don’t match what I see in the literature. Unless they’re saying that James went around high and tripping all the time, which you’d think somebody would notice.

What’s the House team going to do when they encounter someone who actually knows how to close a vent?

So James has Thrombotic Thrombocytopenic Purpura without the thrombocytopenia or the purpura? (OK, they implied a low platelet count late in the episode when they mentioned pancytopenia, but that was the only mention. Purpura? Never mentioned).

Schistocytes can be seen in other conditions besides TTP. DIC, for instance.

The team just gives up when James can’t feel his legs? And this is House’s All Star team?

Whatever happened to the ADAMTS13 testing from the beginning of the show? Might it have remained unmentioned because it would have given the final solution away too early?

Convenient how it was mentioned in the beginning that James’s CT was “clear”, but it was never mentioned what the CT was of…

A few brief words about the soap opera: while I enjoyed the way Cuddy tricked House, I found most of the Cuddy/House/Lucas scenes to be excruciating. On the other hand, I appreciated the fact that both Chase and Taub (especially Chase) were shown to be more devious than previously suspected.

The medical mystery was pretty good this week, but more due to the patient than the mystery itself. I give it a B. The final solution made a certain amount of sense. Spleens can “multiply” after trauma, and there have been cases where doctors removed the largest thinking it was the only one. I give in another B. Overall, the medicine was fairly strong, and earns yet another B. The soap opera had a few good parts, but was weighed down by the House/Cuddy/Lucas scene earning a meager C.

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The House Challenge scores for episode five are up and available here.

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.

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The House Challenge scores are now up to date here.

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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I’ve had several people ask me what I think, medically, of the game Batman: Arkham Asylum and I’m happy to oblige. If posting to the blog seem light this week, you can blame the game.

Overall, it’s a great experience. Though I’m a big fan of video games, it takes a lot for a game to really suck me in to its world completely, and Batman does that (the previous game that pulled this off was the first God of War). The setting, character design, and storyline are all appropriately creepy and the voice acting — especially Kevin Conroy and Mark Hamill — is excellent. Playing the game, I really feel like Batman — I see a crowd of thugs and think, “I can take them, easy,” just like Batman should.

Admittedly, the game isn’t quite perfect:
Riddler’s voice seems flat and tinny, but I just blame this on him using a jerry-rigged radio transmitter.
The final confrontation with Harley Quinn was a definite anti-climax.
Once Poison Ivy joins the big baddies, the atmosphere becomes more cartoony and loses much of its creepiness.

Even with these (admittedly minor) flaws, I’d consider it the best solo super-hero video game.

The Hangman #1
J. Michael Straczynski, writer
Tom Derenick, penciler

A hypothermic patient is brought to the Emergency Room after being caught in a cruise ship explosion. He was in the water for two hours and described as a “near-drowning.” Dr. Dickering (apparently the only doctor in the entire hospital) goes to the ER to evaluate the patient.

The biggest problem in this scene is the doctor’s use of the EEG to look for neurological damage.

Other thoughts:
Intubation is a good choice given that this patient is a hypothermic near-drowning victim and has a high change of developing breathing problems, if he hasn’t already.

An actually core body temperature would be important to know rather than the vague answer of “close to critical.”

Starting to warm up the patient en route is laudable, providing the medics are monitoring his heart, as arrhythmias are common in this situation.

Dr. Dickering sure spends a great deal of time futzing around instead of actually intubating the patient — which is not necessarily a bad thing since the patient is awake and talking — but it does make you wonder why he wanted the intubation RIGHT NOW!

The rest of the scene is little better (I only posted the most egregious panel). The “med-speak” is awkward and lacks the flow one sees in trained professionals. For ER talk done right, compare this scene to the ER scene in Blue Beetle #31. Hint for the aspiring writer: Get a doctor, ER nurse, or paramedic to help with the med-speak, it makes a all the difference in the world.

Here’s a good online case study of a near drowning patient. It’s a pediatric patient, so there are some differences, but it will give you a good feel for how such a situation is handled.

Due to some unavoidable work and family obligations, my medical annotations of Vertical’s collections of Osamu Tezuka’s Black Jack were delayed, but now they should be back on track. Here are the annotations for the first seven stories from Black Jack, Volume 2. My medical annotations of Black Jack, Volume 1 (part one, part two) are still available.

For those of you unfamiliar with the character, Black Jack is a famous — or infamous — maverick surgeon. He is unlicensed, a fact which gets him into trouble frequently, but he is always able to avoid sanction due to his unsurpassed surgical skills.

The writer of Black Jack, Osamu Tezuka, attended medical school, but chose to become a mangaka rather than a practicing physician. Because of his training, his stories are quite accurate. Most of the medical discrepancies are due either to the advance of medicine in the three decades since the stories were written or to differences between Eastern and the Western medicine. Black Jack, like all of Tezuka’s manga, is phenomenal, so if you have any interest in manga or medicine, you should take the time to track down and read them if you haven’t already.

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

Read more…

Cut off a limb and two more shall take its place! But injure the heart…and they’re not quite sure what to do.

It looks like the poor Hydra agent is literally trying to massage the victim’s chest — and the victim sure seems to be enjoying it.
And the “two minutes to brain damage”? That’s about three minutes off. Five minutes of oxygen deprivation seems to be the minimum required to cause permanent brain damage.

Scene from Captain America #274 by Kraft and Zeck

I wanted to like this episode of House, I really did, but the absolutely horrible medical care just wouldn’t let me.

There is an accident during a ballet recital, and 21 year-old ballerina Penelope drops to floor, gasping for breath. She is admitted to House’s service and found to have lungs that “keep collapsing” despite the use of chest tubes. Supplemental oxygen can only raise her oxygen saturation to 60%. The team reports that there are no tumors is her lungs and no evidence of any lung punctures. There is also no bruising, trauma, or evidence of sexually transmitted diseases. Her white blood count and temperature are normal, ruling out pneumonia. House suggests a pulmonary contusion, but it is pointed out that her CT scan was normal. He then decides that she is dehydrated and this is masking her pneumonia, so he orders her started on intravenous fluids and antibiotics.

When Penelope fails to improve on the antibiotics, House wants to do a more invasive test to look for the pneumonia. He is told her lungs can’t tolerate a bronchoscopy, so House decides on a transtacheal aspiration. As always seems to be the case, there is a complication during the procedure. This time, her skin starts sloughing off — not just a little bit, but almost all of it. An autoimmune disease is suggested as a cause for the skin problem. House tells them that he is suspicious a liver tumor has caused the lung problem (by eroding into the lungs). Furthermore, he tells the team that her skin problems is toxic epidermal necrolysis — caused by the antibiotic they gave her.

An ultrasound shows a liver mass. The team can’t perform a standard liver biopsy because without her skin, she is at an increased risk of bleeding out. Instead, they go with a transjugular approach. They obtain the liver biopsy and it is negative for cancer, but she is knocked into the abnormal heart rhythm atrial fibrillation. Wilson suggests giving her metoprolol to lower the heart rate, but Foreman rather brusquely shoves the idea aside. The team has apparently decided that the atrial fibrillation must be caused by something within the heart itself, and want to get an MRI of the heart to get a closer look. Unfortunately, the very atrial fibrillation they are concerned about means that they would be unable to get good results from the scan (the heart would be beating too rapidly and irregularly to get a clear image). They decide to stop her heart, take the MRI, and then restart the heart. To prevent brain damage, there is a strict 3-minute deadline. Foreman thinks he sees something in the aorta, but by then the three minutes are up and the MRI is halted.

House agrees that Foreman saw something in the aorta. The differential now includes tumor, scar tissue, or abscess. Looking at Penelope’s boyfriend, House thinks he is spending so much time with her because he feels guilty, so House deduces that the boyfriend must have given her gonorrhea, which led to an abscess in her heart. The boyfriend is tested and sure enough, he has gonorrhea — only he got it from her and not the other way around. Meanwhile Penelope goes into septic shock and they can’t operate to remove the abscess until she’s stabilized. The team decides to give her dopamine (a medication used to raise the blood pressure in critically ill patients) in order to stabilize her. It works, and Chase is able to remove the heart abscess, but unfortunately the dopamine has cut off the blood flow to her hands and feet and they are turning black and starting to die (dopamine can cause occlusive vascular disease). Chase recommends that she has them amputated, but she refuses. After a fair amount of bickering among the team, Taub decides to go with the Hail Mary pass of injecting her with vasodilators to open the closed off blood vessels. Miraculously, it works and her hands and feet are saved.

House’s hallucination of Amber persists. He tells Wilson what is going on, in a round about way, and insists it must be sleep apnea — but he knows it isn’t, because the symptoms don’t fit at all. A sleep study is normal; no apnea. He has a blood test to look for infection, but it is negative as well. He decides the guilt he is feeling about causing the patient to develop TEN is a symptom of multiple sclerosis, but the tests for MS are all negative. He is down to two causes for the hallucinations: schizophrenia or his Vicodin use. He knows schizophrenia doesn’t really match, but he wants it to be that instead of the Vicodin. But eventually House realizes it must be the Vicodin causing his problems and asks Cuddy to help him go through the unpleasantness that is narcotic withdrawal, because she knows him best and won’t let him get away with anything.

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

It’s not clear to me exactly what caused Penelope’s lung collapse that started the whole business. Was it the heart abscess? The show more or less implied it was, since the team felt that solved her problem, but I don’t know how a heart abscess would cause her lung(s) to repeatedly collapse.

They might have been able to raise her oxygen saturation above 60% if they took her off the nasal canula and used a proper oxygen mask instead.

In this episode, the writers are having a bad case “having your cake and eating it too” in terms of Penelope’s heart abscess. The abscess that is walled off, sealing the bacterial infection away from the rest of her body, making it much harder to detect and treat. However, despite being walled off, the abscess is able to:
Cause septic shock
Deflate the lungs

When we talk about dehydration hiding a pneumonia, we’re talking about the x-ray. An infiltrate (the sign that appears on x-ray showing a pneumonia) does not show up well in a dehydrated patient. Give them some IV fluids, repeat the x-ray, and boom — there’s the infiltrate. Dehydration does not mask the other symptoms he mentioned (temperature, white count — if anything, dehydration will falsely elevate the white count).

You cannot draw a “Vicodin level”. You can draw an acetaminophen (Tylenol, paracetamol) level, but not an hydrocodone level (the two drugs which make up Vicodin). Wilson could have been talking about high acetaminophen levels (which causes irreversible liver damage), but his tone and presentation suggested he was talking about the narcotic component.

The time course of toxic epidermal necrolysis makes it more likely the condition was caused by Penelope’s use of medication (say non-steroidal anti-inflammatory drugs for sore muscles from ballet) than by any antibiotics she received in the hospital.

Lack of overlying skin should not prevent a standard liver biopsy since it doesn’t decrease her blood’s ability to clot. (You could argue that it should be avoided because it would raise the risk of infection, and I’d buy that, but that’s not what they mentioned).

While I agree the heart monitor was showing a narrow complex tachycardia, it didn’t look like atrial fibrillation to me (way too regular a rhythm, for one).

Speaking of atrial fibrillation, I would have liked them to look a little harder at other causes (say thyroid) before immediately deciding it was something within her heart.

While metoprolol controls the rapid rate of the atrial fibrillation, it doesn’t covert it to a normal rhythm. There are other medications that can do that.
I’m not an electrophysiologist, but whenever I’ve seen someone’s heart stopped electrically, they’ve used internal leads, not external paddles.

A “negative ANA” does not magically rule out all autoimmune diseases. Plenty of people have an autoimmune disease without a positive ANA.

A transtracheal aspiration involves a needle, a tiny catheter, and saline. There is no knife — nothing needs to be cut!

Did they ever convert her out of a-fib, or is she still in it (or did removing the abscess clear that up)?

I assume they put her on a heart-lung machine during surgery, but it would have been nice to mention, since they made such a big deal out of stopping the heart earlier.

Eye protection in surgery, team.

The medical mystery was okay, or it would have been had they stayed with it (I’m still wondering what caused her lungs to collapse), so I’ll give it a B-. As I’ve mentioned above, the final diagnosis doesn’t really fit the presentation, or her complex of symptoms. It earns a D. The medicine overall? Well, take a look at the sheer length of this week’s list of concerns and tell me how it can earn anything other than an F. The soap opera was good, but I feel it could have been better. Still, I’ll give it a B+.

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They almost made it for a complete episode without screwing up the science…almost.

The Plot: Strange murders have been occurring in Boston, murders where the victim has their spinal column ripped open and have been drained of spinal fluid. Agent Dunham and her team are called in after the second murder. While examining the body, Walter finds traces of Treponema pallidum, the bacteria that causes syphilis — only it’s a variety of syphilis that has been extinct for decades. They trace the syphilis to the CDC who note that they recently sent a sample of that very syphilis to Lubov Pharmaceuticals. The CDC also mentions that the same research lab ordered RND-390, a component of the rapid skin growth bioweapon seen previously.

Olivia and her team raid the lab — only it’s not a real lab, just a split-level house in a residential area. They arrest a wheelchair-bound scientist named Boone and bring him in for questioning. He admits to working for the ZFT and having developed the rapid skin growth weapon, as well as playing a role in whatever is terrorizing the city now. He tells Dunham that he will help her, only they need to rescue his wife who was kidnapped by the ZFT to ensure he keeps working for them. Eventually, Boone admits that his wife is not a hostage, but has been dosed with a contagion that has turned her into the killer stalking the city. If Dunham and her team can capture his wife, he will concoct an antidote and then tell Dunham everything he knows about the ZFT.

Dunham, Peter, and Charlie capture the wife and brings her back to the lab where Walter and Boone have concocted an antidote. The cure is a success, unfortunately Boone died of a stroke while making it. He leaves a videotape for Dunham naming names. He doesn’t know much, but reveals to her that the money man behind ZFT is William Bell.

1. Free Samples
The CDC is a little free with their germ samples, aren’t they? Particularly the bioweapon ones.
And they know the lab is in a residential area, but don’t seem to think twice about it.

2. It Goes to Eleven
How does giving cerebral spinal fluid to his wife going to cause Boone to become paralyzed? If that’s the case, then everyone who ever had a spinal tap would be in a wheelchair.

3. FBwhat?
Astrid gets the “Only Agent Actually Investigating” Award for her finding-the-club-stamp moment.

4. Billy Squire
Taking too much spinal fluid is not going to cause a stroke; if anything, it’s going to cause a herniation (the brainstem is pushed downward over sharp bony prominences and damaged — and not in a good way). At the least, it’ll give him a nasty spinal headache.
Because it’s not a stroke, the medication tPA (tissue plasminogen activator, a “clot busting” drug) is not going to do any good. And even if it were a stroke, tPA is not necessarily a good idea. If it is a stroke caused by a clot, then tPA is indicated, but if it is a stroke caused by bleeding in the brain, then tPA will make it worse. There are very specific rules about giving tPA to minimize the risk of bad outcomes.
Regardless, you don’t stab someone in the neck with a syringe of the medication.

5. K.I.S.S.
Why inject the antidote into the spinal column at the cervical spine (neck level)? It’s a tough shot, and runs a risk of injuring the cord. Since the CSF circulates throughout the spinal column as a whole, injecting the medication at the lumbar level will have the same effect, only be easier and less risky.

Everything was going for this episode, and I was going to move the clock back again, but then they started talking about stroke and tPA and lost all benefits. The clock stays in place this week.

Big spoilers in the write up of this week’s episode of House, so don’t read it until you’ve watched the show. Overall, the medicine was good, though I would have liked to have seen more of it.

This was really an episode with a split personality. Half the episode was spent on Kutner, and only half was spent on the patient (or in this case patients) of the week. While Kutner certainly deserved the time he received, I think the medical mystery got short shrift as it had some really nice twists and turns that would have benefited from receiving more time.

Eddie is dying of lung cancer related heart failure, and is under hospice care at home. Sensing his time is near, he asks to be alone with his wife Charlotte to give her a final goodbye. In the midst of their tearful farewell, Charlotte suddenly begins gasping and struggling to breathe before collapsing. Shocked, Eddie struggles to sits up and calls out for help.

Charlotte is admitted to House’s team for evaluation of her acute respiratory failure. Her history is unremarkable except for a trip to Hawaii six months ago with her sister. Foreman suggests she may have contracted melioidosis (a tropical disease that was the culprit in episode nine) there, but the idea is dismissed in favor of Taub’s suggestion of varicella zoster (the virus that causes chicken pox; it can cause a nasty pneumonia if contracted as an adult). House wants her started on acyclovir (an antiviral drug that’s good against varicella), but she refuses treatment because she wants to be with her husband. She reports that he seemed to get better when she became sick, so it appears she will be able to spend more time with him before he dies. Taub solves the problem by wheeling her husband’s bed into her room so they can stay together.

Charlotte gets better with treatment, but Eddie starts to decline again. A short time later, Taub is called to the bedside when Charlotte starts gasping for breath. The respiratory technician tells him that her oxygen saturation is normal and it doesn’t appear to be her airway. Her lungs are normal on exam, and her heart rate, though rapid, is regular. Once again, Eddie gets better when he sees Charlotte sick. Her cardiac enzymes were normal, so that makes a heart problem unlikely. House rules out a mitochondrial disease because the vision is normal. The team then suggests a metabolic disease causing acidosis or polyserositis. House likes the latter suggestion, so starts Charlotte on indomethacin (a potent anti-inflammatory drug).

Unfortunately, Charlotte doesn’t improve on the indomethacin. Eddie, on the other hand, continues to show subtle signs of improvement. Deciding that polyserositis was the wrong diagnosis, Taub considers then quickly discards Wegener’s Granulomatosis (a disease that commonly affects the lungs and kidneys), Byssinossis (“cotton worker’s lungs” or “brown lungs” — a lung disease caused by a bacteria that lives in cotton), and mitral valve stenosis. House decides that there is only one likely diagnosis, so heads to Charlotte and Eddie’s room and confronts her. He tells her that since Eddie is improving while he is worried about her, she is faking being sick so that he will continue to improve. Grudgingly, she admits that House is correct, then she screams, complaining of left leg pain. House is doubtful, but when he examines the leg he sees muscle atrophy and petechiae, he realizes that something is truly wrong with her.

Multiple sclerosis seems a likely diagnosis, so she is sent to get an MRI of the brain to look for the telltale signs of the disease. She passes out while undergoing the procedure and is found to have a ruptured spleen. While Chase is performing an emergency splenectomy, Taub wants him to look for signs of rheumatoid arthritis. He doesn’t find any, but he does find that her liver is scarred, so whatever she has is getting worse. The team discusses and discards the diagnoses of autoimmune hepatitis and amyloidosis. House suggests alpha-1 antritrypsin deficiency (an inherited disease that attacks the liver and lungs) and orders the appropriate test (AAT). Eddie has an echocardiogram which shows he still has very severe heart failure with only a few days, at most, to live. Meanwhile, Taub has a conversation with Charlotte where she tells him that if she dies before Eddie, she would like him to get her heart for transplant. A short time later she is found seizing on the floor — she had broken into the crash cart and injected herself with all the medication she could find. She is resuscitated, but her liver has taken more damage from the drugs and she only has about 24 hours left to live. In the meantime, the AAT test has come back normal. Thirteen now suggests that Charlotte may have myelofibrosis (a disorder of the bone marrow), but mentions that the test for it takes longer than Charlotte has to live. House’s first idea is to lie to the transplant committee and say that Charlotte has myelofibrosis so she can get a liver transplant. But then he has a more devious idea. He wants Eddie to give Charlotte a partial liver transplant. Of course, a partial transplant won’t help Charlotte for long, but House understands this. He also knows that Eddie is so sick it is unlikely he will survive the surgery and will almost certainly die on the operating table, thus leaving an entire liver to transplant into Charlotte. House convinces Cameron, the “incurable romantic,” to discuss this with Eddie. He agrees to the surgery, fully realizing that he will die during the surgery, and understanding that he is dying so that his wife can receive his liver and survive.

Cameron tells House that Eddie has agreed to his plans, but she also mentions that she noticed nodules on his hands and suspects his heart failure may be caused by something other than lung cancer. House investigates and sure enough, Cameron was right. Eddie doesn’t have lung cancer, but instead a fungal infection (blastomycosis) that caused lung nodules that were mistaken for cancer, and then caused his heart failure. It is a curable disease, but Eddie is having none of it and refuses treatment — he wants to die for Charlotte so she can have his liver. Across the hospital, Charlotte is doing worse. Her fever is spiking and the lumbar puncture shows bunches of white cells (a sign of infection). Taub mentions that she is “infected everywhere.” Still unsure of her diagnosis, the team considers sarcoidosis and scleroderma. Taub then makes a comment about guilt and love, and House has his Eureka! moment of the week. It turns out that Charlotte was lying about her trip to Hawaii. She really snuck off the Rio with some other guy, and while there she contracted visceral leishmaniasis (a nasty parasitic infection of the organs, i.e. the viscera). She is started on antimony for treatment and a transplant is arranged, but it is tool late and Charlotte dies with Eddie by her side.

I don’t have any huge medical complaints this week, other than the ethics of the partial (wink, wink) liver transplant — I’m surprised Cameron agreed to go along with it. Sure, she’s the romantic, but she also been shown to have the strongest sense of ethics.

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

Why did she improve on the acyclovir if her symptoms were caused by leishmaniasis?

House was discarding diagnosis left and right for incorrect reasons. For example:
No vision problems, can’t be mitochondrial. Wrong!
Normal thyroid, can’t be autoimmune hepatitis.Wrong!

Severe blastomycosis (like that causing heart failure — a rare situation) needs a stronger medication than Itraconazole.

It would be easier to diagnose rheumatoid arthritis with blood tests than a splenic biopsy.

It doesn’t take 48 hours to test for myelofibrosis.

Most of the suggested diagnoses fit the case better than usual this week (though most still required quite a bit of stretching); on the other hand, they also skipped over a bunch of possible causes — more than usual — probably due to lack of time.

I thought the scenes relating to Kutner were well done. His death seemed very abstract at first as it occurred off camera and the way they just showed the his legs and trunk through the doorway lent it an air of unreality. I liked the way they showed how the situation affected each character, and everyone reacted differently, though ultimately within character.

I’m sorry to see Kal Penn leave the show. He should be proud though: between playing Kutner, Kumar, and appearing in the last Superman movie, he’s completed this nerd doctor’s trifecta.

With the eminent thespian Meatloaf playing Eddie (who shares a name with the character he played in the Rocky Horror Picture Show), I hope you know how hard it was for me not to make any Bat Out of Hell Jokes in tonight’s write up.

Well, just one: Kutner may be gone, but Taub and Thirteen are still around and Two Out of Three Ain’t Bad.

The medical mystery was good, though would have benefited from the full time, not just the half it got. It deserves an A-. The medicine was sketchy in places, but fit the symptoms better than usual and earns a B. The final solution was clever and (mostly) logical, and earns another B. The soap opera was the star of this episode, and was very good. I give it an A.

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An interesting concept felled by extremely poor medicine on this week’s episode of House.

Lee is a roofer who ends up in the ER after a bicycle accident. He has suffered head trauma and appears to be brain dead, so the ER physician is ready to call the organ transplant team. Luckily, House is in the bed next to Lee after a minor motorcycle accident. He recognizes that Lee is showing purposeful eye movement so he cannot be brain dead. He realizes that lee is suffering from Locked-In Syndrome. Lee is able to communicate with House by blinking his eyes in response to yes or no questions. The hospital doctor believes that Lee’s brain damage was caused by the crash, but House suspects it was the other way around: Lee’s crash was caused by the brain damage (and Lee’s memory seems to back this up when he sees the car door but is unable to work the brakes on his bike to stop in time to avoid the collision). House’s initial differential diagnosis is fairly general and consists of stroke, cancer, or infection. The rest of his team (excepting Taub) shows up at the ER. Foreman suggests a basilar artery stroke, Kutner suggests cardiovascular disease, and Thirteen suggests a tumor. House thinks Thirteen’s idea has the most merit so he forges a set of orders for the patient to get an MRI.

The MRI is normal, though House imagines he can see a lesion in the central pons. He continues to believe that Lee has a tumor with an associated paraneoplastic syndrome. The hospital doctor disagrees and has diagnosed Lee with an infection of his central nervous system and so has him on antiviral medication (apparently suspecting a herpes, varicella, or CMV infection). The medications don’t work and Lee suffers a seizure. House reports that Lee needs plasmapheresis. Lee’s wife believes him and has Lee transferred to Princeton Plainsboro Hospital . Once there, the team discovers that he has blood in his urine. Thirteen suggests Marchiafava-Bignami Disease (a rare, progressive neurological disease seen in alcoholics). House decides that a brain biopsy is the key to discovering what the underlying disease is. In the middle of the biopsy, Lee loses his ability to blink — which was his only way of communicating. It’s not clear to the team why Lee can no longer blink — or even if he is still alive or brain dead. The worsening symptoms could be caused by a botched biopsy, brain swelling caused by the procedure, or it could be from an as of yet undetermined cause. The differential now includes Epstein-Barr virus, malaria, picornavirus or rotavirus.

Taub suggests using a brain computer interface to allow Lee to communicate. It takes some time and coaching (and pleading) by Taub, but Lee is eventually able to answer yes or no questions with the interface. While interviewing Lee about travel, his wife tells the team he had recently been in St Louis, but Lee tells House “no” to this. It turns out he lied to his wife, and was not out of town at all. At first, House thinks some hanky panky may have been going on (meaning that neurosyphilis would be a possible diagnosis), but he later learns that Lee was staying at a friend’s basement while he was cranking out resumes and applying for jobs because his roofing business was having financial troubles. The team also learns that he had been moonlighting as janitor for a local factory that made rechargeable batteries. Kutner and Taub search the factory and find cadmium dust, suggesting that Lee may have heavy metal poisoning. He is started on chelation therapy.

The chelation therapy does not seem to be working, and Lee has been frequently complaining (to himself, since no one else can hear him) of eye pain. Thirteen takes a close look with fluorescein dye (an orange dye that fluoresces green under black light if there is corneal damage) and diagnoses him with ulcerative keratitis. To House, this means that Lee either has an infection like varicella (the virus that causes chicken pox and shingles), or an autoimmune disease like Behçets Disease. Neither condition really fits well, so Cameron recommends that he perform a lumbar puncture (i.e. a spinal tap) and let the results guide his treatment. As the team is explaining the lumbar puncture procedure to Lee, he suffers a cardiac arrest. The team manages to successfully resuscitate him, but now he complains of an itching foot. To House, this mean that Lee has liver failure. When reminded that Lee’s liver enzymes are normal, he tells them that they had been high, but as the liver failure became worse and the liver died off, the levels dropped and now appear normal. He now believes that it is the liver failure which is causing the locked-in syndrome. Sclerosing Cholangitis (an autoimmune disease of the bile ducts and liver) is the team’s main diagnosis. They are preparing to perform a liver biopsy when Kutner realizes that Thirteen developed a rash where her skin had come in contact with Lee’s urine. Therefore there must be something infectious in his urine that caused her rash and Lee’s symptoms — and the likely cause is Leptospirosis. Sure enough, there were rats positive for leptospirosis in his friend’s basement. He caught the disease from them which caused his liver failure which then caused his locked in syndrome. Antibiotic treatment is started and Lee is able to move a finger again.

The concept of a patient who could only communicate with yes/no answers was clever, but the medicine was very sloppy this week.

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

How did the liver failure affect just the one tiny portion of the brain to cause the locked-in syndrome? Why wouldn’t it affect the rest of the brain?

For the 1,732nd time: Don’t shock a flatline.
A recent study suggests bad habits learned from television medical dramas are a major reason medical students and residents are having trouble intubating patients correctly. I hate to think what that means for treating cardiac arrests…

Why was House suggesting that Lee needed plasmapherisis? It is used for treatment is certain cancers, but these are blood cancers, and nothing that fit Lee’s scenario.

It is true that in people with advanced liver failure the liver enzymes do seemingly return to normal levels. But by then, other symptoms of liver failure have been long evident. None of which Lee showed.

Liver failure can cause pruritius (itching) because of the elevated bilirubin. But it wouldn’t show up as just one foot — and the bilirubin level would be markedly elevated on the liver function test (but you notice the team only mentioned the “liver enzymes” were not elevated. Bilirubin in not a liver enzyme, though it part of the same common liver test).

Locked-In Syndrome takes a very long time to improve (not just a few days), and that’s even if the patient gets better and most don’t (actually, most die within 4 months of diagnosis).

Leptospirosis causes uveitis, not keratisis, which wouldn’t show up on fluoroscein staining.

Liver failure that advanced would probably require a liver transplant, not a few days of antibiotics.

The medical mystery was very clever, though it seemed a little too conveniently clever for its own good, still I’ll give it an A-. The final solution was an incredible stretch and earns a D. The medicine was scarcely better and earns a C-. The soap opera was only average. Taub was mildly interesting, and neither House nor Wilson seemed to have their heart in their scenes. C.

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

A good episode of House with a fascinating premise and some good soap opera and social moments. The medicine was average, but didn’t hurt the episode much.

Nick Greenwald is a successful book editor who, while at a party launching his star author’s latest book, finds himself blurting out truth after uncomfortable truth to those around him. He then develops a nosebleed and collapses.

Nick is admitted to House’s service where the team notes that he reminds them of the classic case of Phineas Gage (a railroad worker who suffered personality changes after a spike was driven through his brain). Nick is showing signs of frontal lobe disinhibition, but there is no sign of a frontal lobe tumor as his head MRI is negative. Thirteen suggests that there may be a tumor hidden in the nasal cavity, but a nasopharyngoscope shows nothing. Next, an fMRI (functional MRI — an MRI that looks at blood flow within the brain) is obtained and reveals an abnormal area in the cingulate gyrus. Thirteen remarks that it’s too near the brainstem to biopsy, then Foreman mentions that it might be neurosarcoidosis (sarcoidosis which affects the central nervous system). Steroids are started to treat the presumed sarcoidosis.

Nick suddenly becomes very short of breath. Foreman states that it’s not his heart because the EKG is normal, so it must be kidney failure, and starts him on dialysis.

The differential now includes systemic sclerosis and chronic lymphocytic leukemia (both of which are quickly dismissed), as well as diabetes, and some sort of “congenital genetic disorder.” Foreman points out that there are too many genetic disorders to test for them all. House has Taub run a glucose tolerance test to check for diabetes, and has Kutner check Nick’s daughter for peripheral nerve damage because she suffers from some ill-defined neurological disorder and he thinks the condition might be inherited. The peripheral nerve test is normal, and Taub reports that the glucose tolerance test was completely normal and never above 120 for the entire night. House now wants to check the thyroid, but before the test can be ordered, Nick develops a fever, coughing, and pulmonary edema. Kutner orders 200MG of furosemide (a diuretic) and 2MG of morphine (primarily a pain killer, it also helps with pulmonary edema).

With Nick’s temperature at 103° (39C), the team now considers infection as the likely cause of his symptoms. Foreman mentions Staph aureus, tuberculosis, and strongyloides (threadworm). Kutner determines that a stray dog is living with Nick’s family and he and House suspect that Nick has developed Weil’s Disease (leptospirosis — an infection caused by the Leptospira genus of bacteria). He is started on doxycycline (an antibiotic) and his condition improves. Kutner and Foreman tell him that while the infection is cured, his brain damage and disinhibition are going to be permanent. Nick wants surgery to remove the damaged area, but they tell him it is too risky. He talks to House, who apparently sees some of himself in Nick, and talks Chase into getting his boss — a neurosurgeon — to perform the surgery. Initially, the surgery seems successful, but then it quickly becomes clear that Nick still blurts out whatever crosses his mind. That’s not all though, as his temperature starts falling dangerously low and he develops unstable ventricular tachycardia (and this is the right time to use the paddles). The arrhythmia is corrected and an echocardiogram is obtained, but shows no structural heart damage. Nick continues to have an abnormal temperature. The differential diagnosis now leans toward cancer, but Foreman rather cavalierly dismisses the idea. He orders a full body scan. This shows a small abdominal aneurysm (dismissed as an incidental finding), a cyst in the pleura (the membrane surrounding the lungs — also dismissed as an incidental finding), and a density in the liver. Foreman suspects this density represnts an ateriovenous malformation (AVM) and that multiple AVMs would explain the patient’s condition. He wants to go forward with angiography with embolization (a test to find and then block off the AVMs).

House is in New York with Wilson, but the team is texting him to keep in touch. In the middle of a conversation about Wilson’s guilt over his schizophrenic brother, House has his Eureka! moment. The glucose tolerance test that was normal should not have been normal because Nick was on steroids, which raise a person’s blood sugar. The fact that it did not rise, combined with the cyst — which is really a fibroma — in the pleura means that Nick has Doege-Potter Syndrome (a fibrous tumor that secretes insulin-like compounds and causes low blood sugar; Kutner mentions human growth hormone, but other similar chemicals can also be secreted). Nick has also developed an autoimmune reaction to the tumor, and his immune system has gone into overdrive and attacked his own body (brain, kidney, heart in this case). Removing the tumor should solve his problems — the medical ones at least.

They’re really weren’t any huge medical errors this week, just the usual hodge-podge of symptoms and diagnoses that really don’t fit. The worst was Foreman’s clueless statement about cancer, so that gets the prize this week. Well, there was also that one scene, but I’ve already spent enough space talking about it.

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

A normal PSA, normal colonoscopy, and normal blood count absolutely do not rule out cancer. Admittedly, colon cancer and prostate cancer are the most common cancers in a man Nick’s age, but there are plenty of other cancers out there (plus there are concerns about how reliable the PSA test actually is).

Diabetes doesn’t really fit his symptoms at all — other than the kidney disease. Of course, it was just an excuse to run the glucose tolerance test.
Speaking of the glucose tolerance test, the patient needs to be fasting, and it doesn’t take 12 hours to run.
It’s true that the steroids should have raised Nick’s sugars, but even a normal patient whose blood sugar didn’t rise above 120 after a hefty glucose load would be unusual.

Brain damage and peripheral nerve damage are two different things. It’s more common to have one without the other than both together.

If Nick’s kidneys are shot and he requires dialysis (a very important fact that was never mentioned again in the show; the dialysis that is, not the kidneys), then even 200MG of Lasix is not going to have any effect.

An MRI of the brain should have shown any nasal cavity tumor, especially one that was eroding into the brain.

Too many genetic disorders to test for them all? But they tested for them all in at least two previous episodes.

House doesn’t like full body scans? Then why does the team order them so regularly.

A cyst is hollow, a fibroma is solid. A scan should be able to tell the difference.

I thought the medical mystery was good this week, it was interesting not only from a medical perspective, but also fascinating from a social perspective. It made me wonder what horrible secrets I might spill. I give it an A. The solution was fairly logical, even if it did require two diagnoses (Doege-Potter + autoimmune). It earns a B+. The medicine was average for the show and I give it a C; it might have scored higher had that one scene been clearer. The soap opera was the best part of the episode. There were good House/Wilson and House/Taub interactions (the squash racket was great), and the patient’s social interactions were like a car crash: painful, but impossible to look away. The soap opera earns a solid A.

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

The scores for this episode’s and last episode’s House Challenge scores have been posted.

The 100th episode of House. Too bad it was so absolutely mediocre with an unlikable patient.

Of course, this also makes it my 100th House review*. Sure the first reviews were just a paragraph or two, but they quickly evolved into the behemoth you see before you now. While it’s certainly true that the quality of the show has suffered some over the past few seasons, it still remains the best medical show, if not best show outright, on television.

Dana Miller is assisting a chef in teaching a cooking class when she becomes short of breath and starts to cough. She discovers that her lips are blue and realizes she has cyanosis. She complains of pain in her chest and back and diagnoses herself with a spontaneous pneumothorax before collapsing on the floor. She is rushed to the hospital and admitted to House’s service, primarily based on her name and reputation. It turns out that Dana is a rock star in the world of the cancer research, and said to be on the cusp of finding a cure for retinoblastoma. The team is sorely disappointed when she tells them that she gave up her career in medicine eight months ago after uterine surgery because she realized it wasn’t making her happy. She now devotes her time only to activities that she fully enjoys.

There is no clear cause for Dana’s pneumothorax. Foreman points out that there is no history of COPD (chronic obstructive pulmonary disease, i.e. emphysema) and no history of tobacco use or recent scuba diving. The initial differential diagnosis consists of cystic fibrosis, lung cancer, or an undiagnosed asthma. She is started on steroids to treat the suspected asthma and a CT scan of her lungs is obtained to look for evidence of hyperinflation (a sign of asthma). The CT scan is normal, making asthma less likely. Taub suggests that lingering damage from the central line from her surgery might explain the lung problem (and I couldn’t help but notice that instead of just stating she had “surgery,” he was very specific about which surgery she had. Hmmm. Wonder if this will be important later?). Kutner notes increased interstitial markings on the CT scan — which apparently everyone else missed — which means that Dana might have pulmonary fibrosis. A biopsy is ordered. When Taub is explaining the test to her, she starts to complain of left-sided abdominal pain. After a quick exam, Taub tells her she has bleeding into her abdominal cavity and withdraws a syringe of blood to prove it. (FYI: She asks if she has ascites, the build up of fluid in the abdomen).

In addition to her lung problem, Dana now has a liver problem — or problems — as well. Not only is her liver bleeding into her abdominal cavity, but they also work in the fact that she has liver failure. Foreman suggests a liver granuloma as a possible cause, and Thirteen goes one step farther and suggests blastomycosis as the cause of the granuloma. A biopsy is obtained, but the test for blastomycosis is negative. Dana starts to complain of itching, which she blames on the liver failure (the high bilirubin levels that occur in liver failure can definitely lead to very bad itching). As she sleeps, she continues to scratch, and in fact scratches hard enough that she scratches through her skull into her brain. Luckily, Taub is able to repair the skin damage (having a plastic surgeon on the team is sure handy) and announces that she has suffered no brain damage.

The differential now consists of psychogenic itching, meningitis, encephalitis, multiple sclerosis, or a brain tumor. An MRI of the brain is obtained and is negative. House now suspects that Dana has polyneuropathy and wants to shock the affected areas to “reboot” the nerves. As Taub is about to start the treatment, she begins to experience a shocking sensation — which he identifies as Lhermitte’s sign. According to the team, this can be suggestive of Behçets Disease, Vitamin B12 deficiency, a demyelinating disease, or a spinal hemangioma. An MRI is ordered to look for a hemangioma. It turns up what appears to be not just a single hemangioma, but hemangiomas in the spine, lungs, and pericardium (the sac surrounding the heart). The thought now is that she has metastatic mesothelioma (a lung cancer most commonly associated with asbestos exposure), but House is perplexed that these same lesions did not show up on the chest CT two days before. Wilson is called in to biopsy one of the lung lesions, but he is unable to perform the procedure as the lesion starts bleeding profusely, which should not happen if it is mesothelioma. He suggests she might have arteriovenous malformations (AVMs) due to schistosomiasis (a parasitic infection acquired from bathing or swimming in contaminated water), but the team counters that she shows signs of Gorham’s Disease or Kasabach-Merritt Syndrome. The brainstorming is interrupted when Dana suffers cardiac tamponade (blood fills the pericardial sac, compressing the heart and not allowing it to beat correctly). Kutner inserts a needle (read: jams a needle blindly) into her chest to relieve the tamponade, only now she is bleeding copiously through her ears, nose and eyes.

Later, Taub informs House that they are giving Dana multiple units of platelets and FFP (fresh frozen plasma) but they cannot control her bleeding. House suggests embolization — blocking off the bleeding blood vessels. He wants them to start with the ones in her lungs. He then proceeds to run into Cuddy, where in the midst of a crasser than normal conversation, he has his Eureka! moment. He reveals that Dana is bleeding so heavily because it she is menstruating. He announces that as a result of her uterine surgery she has developed endometrosis, and it is these abnormal clusters of endometrial tissues throughout her body that are doing the bleeding.

Thirteen begins to have frontal headaches. Foreman is concerned that it may be related to the experimental Huntington’s drug, but she blows it off, telling him that she has been taking the drug or the placebo for weeks now, and nothing has changed recently (Right? Right? Wink wink.) House then brings her lack of peripheral vision to Foreman’s attention. He tests her himself and finds that House is right. He confesses the truth that he switched the drugs to her, and obtains an MRI of her brain. It reveals a tumor in the optic chiasm. Within a day or so, she becomes totally blind. House and Foreman give her a directed radiation treatment to the tumor, and it regresses and Thirteen’s sight is restored. As the episode ends, Foreman confesses what he did to the drug company running the trial. He is kicked off the trial, but gets to keep his license. On the other hand, Thirteen’s data, now considered dirty, is excluded from the trial and so is the evidence that the drug may cause tumors.

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

I had pretty much given up on even mentioning the errors in the procedures the team performs, but this week two scenes were so bad that they bear special mention.
First, Taub drawing the blood from the abdomen. He did just about everything wrong. No protection for him. God forbid he sterilize or at least clean the patient first (congratulations Taub, you just gave her a staph infection of the abdomen). You need to use a z-track technique or the higher pressure in the abdomen will push the fluid out the needle track. That 20- or 40-cc syringe was way too small to draw off any appreciable amount of fluid. I have seen multiple liters pulled off a single patient (though admittedly, those patients looked pregnant).
I have similar complaints in regards to Kutner’s technique for pericardiocentesis. Worst was when he overhand jabbed the needle blindly into her left chest. That is NOT the way to perform a pericardiocentesis. He likely gave her a second pneumothorax, not to mention injured the heart or sheared off a coronary artery. The trick is to drain off the fluid without killing the patient in the process.

There have been documented cases of endometrosis being spread due to surgery, however, in all these cases the patients had endometriosis before surgery, and it was that endometriosis that was spread, not normal endometrial tissue that became endometriosis.
My biggest problem with the endrometriosis solution is the time course. Remember your high school health class. The endometrium takes 3 -3½ weeks to slowly build up in thickness before sloughing off to start the menstrual cycle. Endometrial tissue does not go from nothing to suddenly-detectable-everywhere one day before the cycle starts. If she that much endometriosis to cause all the symptoms she had, there would have been plenty of evidence on the first CT.
Why had she been symptom free the previous 7 months?

Bronchoscopy and bronchoalveolar lavage are the preferred initial steps in diagnosing pulmonary fibrosis. It’s true that they are not as good as an open biopsy, but the risk pf complications are significantly less.

There are many fungi that fluoresce under black light and it is a fun way to diagnose ringworm, but it is not the recommended method of diagnosing blastomycosis. In fact, I didn’t find the technique mentioned in any of the main texts on the subject.

Wow, Thirteen had an incredibly fast growing tumor, didn’t she?
I was amazed at how fast the writers were able to turn it around from “Foreman screwed up” to “Those evil drug companies!”

“House was right” about the hemangioma? I though Taub was the one who brought it up.

I don’t know too many oncologists who do their own lung biopsies.

What explains the liver failure?

Other than the comic-book style shocking visuals, why was Dana bleeding from her ears, nose and eyes? Did she have endometriosis there too (a first), or was the pressure of the bleeding so much it split her skull?

The medical mystery was fair this week. It started out small, but built up over the course of the episode and earns a B. Though I had problems with the final diagnosis medically, I thought it was clever and with a little tweaking could have fir perfectly so deserves another B. The medicine was average again: very superficial with little follow through. It earns a C. The soap opera was good, if understated. I liked the book-ending Wilson scenes, and the House/Cuddy scenes were fun, if a little out of character for her (though she did explain she had been dragged down to his level). I give the soap opera a B.

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

This week’s scores for the House Challenge have finally been posted

*OK, technically it’s my 101st House review as I re-reviewed one of the earlier episodes. One of these days, when I have time, I plan to go back and do the same for the other early episodes.

Another week, another episode of Fringe with painfully bad medicine — only this time with bad computer science as well!

The Plot: A teen age boy is on the computer when he open an anonymously sent program. Strange images begin flickering on the computer screen and he stares, transfixed. His parent find him later, dead, his brain liquefied and oozing from his ears and nose.

Agent Dunham and her team arrive on the scene. They interview parents and friends, but can find nothing incriminating. The grab his computer and take it back to the lab. Astrid tries to look at the hard drive — after all, she has a minor in “computer science” — but announces that she cannot because its platters are fused.

A second body is found, just like the first. This time, it’s a car salesman across town. The computer hard drive shows the same damage, but this time Astrid is able to determine that he had downloaded a shortly before he died. Peter takes both computer hard drives to one of his friends who is not able to track down the sender of the file, but is able to discover that it has been sent to a new location — Agent Dunham’s home. Dunham and Peter rush to her apartment and find her young niece transfixed by the screen. They are able to bring her out of the trance and she appears fine. Dunham does notice that the webcam light is on, suggesting that someone has been watching her.

Another victim is found, this time a day trader in Evanston, Illinois. The killer has gotten sloppy and there is enough information for even Agent Dunham to discover a pattern to the killings. This victim was the new husband of the mother of Luke Dempsey. Luke was the first victim’s best friend. Dunham discovers that Luke’s father is something of an incredible computer genius. She suspects he is the one behind the murders. She brings Luke in, but he won’t tell her where his father is. She lets him go, and follows him to his father’s hideout. She confronts the killer, but in the end he takes his own life.

1. Brain Fondue
Dr. Bishop: A complex combination of visual and subsonic aural stimuli, ingeniously designed to amplify the electrical impulses of the brain, trapping it in an endless loop.
That sure sounds like Dr. Bishop is describing a seizure, or actually a type of potentially fatal seizure known as “status epilepticus“.
People can die from status epilepticus, but their brain doesn’t liquefy.
Speaking of that, how exactly did this seizure-like activity cause the brain to liquefy? Was it supposed to raise the temperature so much the brain melted? That’s really too stupid for words.
And even if the brain did liquefy, why would it leak out the nose and ears? The brain is essentially in a tightly sealed container; it won’t leak out unless the container is broken (a skull fracture, for instance).
Flashing lights can certainly cause seizures in certain people; it’s called a photosensitive seizure and was the reason that one episode of Pokemon was never shown on television in the U.S. But it doesn’t cause seizures in people who aren’t already susceptible.

2. The Brown Note
My speakers can barely play real sounds, let alone “subsonic aural stimuli.”

3. Damn Viruses
Astrid: A computer virus that infects people.
I thought this idea was ridiculous when I first ran across it several years ago in the Cable/Deadpool comic book. Plus, I don’t think this was an actual computer virus. It was malware, certainly, but it didn’t have the self propagating characterstic of true computer viruses.
Yet another reason not to click on spam pop-ups.

4. The American Medical Association
There is no such thing as the “AMA Database.” The AMA is essentially a lobbying organization, it has little to do with the actual practice of medicine.

5. It Didn’t Even Start Well
That is an absolutely horrible episode title.

6. All Your Base Are Belong To Us
I know just enough about computers to realize that most of the “computer science” on this week’s episode was on par with the medicine. I leave it up to all you computer experts to do the critiquing here.

I’m afraid Fringe is rapidly reaching the point where it has gotten so ridiculous that it’s not worth an hour of my time to watch, let alone write about afterward. To this end, I have created the Fringe Doomsday Clock, patterned after the famous nuclear doomsday clock.

When the clock reaches midnight, my patience will be up and I will stop watching Fringe. After the last two episodes, the clock has been moved ahead to 11:57.

It’s nice to have House back after the winter break, but I wish the second half of the season had started with a stronger episode, not this lukewarm time waster.

Jeff is a 32 year old patient with a 3 year history of chronic pain. It started as abdominal pain, but now he also has severe headaches and muscle cramps that come and go. He has seen seven specialists since his symptoms started, but a cause has never been found. He is on high doses of narcotic pain medication with poor pain relief. As the episode starts, he writes a farewell letter to his wife and son and tries to commit suicide, but they come home unexpectedly and find him. He is rushed to the hospital where he is admitted to House’s team.

Thirteen suggests fibromyalgia, but the idea is quickly shot down as Jeff’s symptoms do not match the recognized criteria of the condition. Taub suggests that the patient’s pain is psychosomatic, probably due to an undiagnosed depression. House has Taub run a “pain profile” (i.e. depression screening) on the patient, and Foreman and Thirteen search his house. The search turns up some metal polish — which can cause nerve damage (but the patient worse wore a respirator) — and a freezer full of quail. Quail-related food poisoning (coturnism) can cause rhabdomyolyisis (a disease caused by rapid muscle breakdown). Taub continues to think that the pain is psychosomatic, but House disagrees, believing that Jeff’s depression is caused by the pain and not the other way around. He orders a muscle biopsy to rule out rhabdomyolysis.

In the middle of the biopsy, Jeff complains of sudden right arm pain and his blood pressure drops dangerously low. Kutner announces that he is in “arrest” — though whether it is a cardiac arrest or a respiratory arrest is never clarified (though later comments suggest it was a respiratory arrest). He is found to have a pulmonary embolus by a ventilation/perfusion scan. The differential includes a hypercoaguable state (patients that clot easier than normal) or a cancer syndrome (Trouseau Syndrome is mentioned). Since House is not around, Foreman orders a CT scan of the patient’s chest, abdomen, and pelvis in an attempt to find a suspected tumor. No tumor is found, but edema (swelling) is seen in the intestines and air is seen in the intestinal blood vessels. Kutner suspects that Jeff may have a blockage in his superior mesenteric artery which has blocked blood flow to the intestines and damaged then. Thirteen points out that blood clots elsewhere in the body may be causing his pain. Foreman orders an angioplasty of the artery. Hearing the symptoms, House intervenes and points out that the patient had blown air into his IV, causing an air embolus in a suicide attempt. This is what caused the intestinal edema, air in the intestinal vessels, the pulmonary embolism, and respiratory arrest.

The differential now includes non-motor seizures (discounted because the EEG’s have all been normal) or a glycogen storage disease (an inherited enzyme deficiency) such as McArdle’s Disease. An ischemic forearm test (a test designed to uncover the enzyme deficiency) is performed. It doesn’t show any evidence of the glycogen storage disease, but during the test the pain moves from his left arm to his left leg, the first time that it’s ever jumped like that. The possibility of disc disease is mentioned once, then never again. The team now wants to decide once and for all whether it is psychosomatic pain or there is a physical cause. A total spinal block, high in the spinal cord, is given. This is supposed to separate the mind from the body. If the pain is gone, then the cause of the pain is physical (because the connection between the nerve ends of the body and the pain areas of the brain has been broken); but if the pain remains, then the cause is in the brain (because it doesn’t involve nerves of the body, thus breaking the connection would have no effect). The test relieves Jeff’s pain, but not entirely. This puzzles House because the test results should be all or nothing.

A short time later, House and his team are called to the floor when Jeff’s son Zach starts writhing on the floor, screaming in pain. Jeff’s wife is scared that Zach may have what Jeff has, but House recognizes it as a distraction to cover Jeff’s latest suicide attempt — drinking a bottle of isopropyl (rubbing) alcohol. He is started on dialysis. With the failure of the spinal block to clearly identify a cause, the team now considers Fabry’s Disease (another inherited condition), syphilis, or opiod induced pain (his pain medications are worsening his pain). House decides the last is the most likely, and forces narcotic withdrawal in the patient by giving him naloxone, an narcotic blocking agent. It doesn’t work, and Jeff’s wife convinces House to let Jeff be discharged home with the understanding that he is going to attempt suicide again once he gets home; this time with her blessing.

A short while later, talking to the handyman who is fixing his apartment, House has his “Eureka!” moment and deduces that Jeff has epilepsy (yes, I know they dismissed the idea earlier, but bear with me here). It started three years ago as a seizure in the muscles of the testicle but then spread to the brain’s sensory region and somehow “rewired” the neurons of the brain. It didn’t show up on EEG, House says, because the nerves to the testicular muscles are in the “deep” area of the brain. With treatment for his seizures, Jeff is cured and lives happily ever after.

This seemed to me to be a relatively weak episode medically. There aren’t many specifics I can point at and say they got wrong (but not much I can say they got right either); it’s more of an overall impression. Part of the problem is the vague symptoms — is the patient’s pain all over (as frequently stated) or specific to certain areas (as it seemed to be whenever the plot required). Admittedly, chronic pain conditions are difficult to diagnose and treat, but this was a little too much.

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

As is becoming more common, the diagnoses suggested are way off from the patient’s actual signs and symptoms. McCardle’s Disease, Fabry’s Disease — really?

I think it’s pretty clear that neither Foreman, the nurses, nor the writers have any idea what a double blind experiment actually entails.

Speaking of no idea, Cuddy’s right: the team (and floor nurses) seem to have no idea what “suicide precautions” are. What were they, 0-2 for the night?

The medical mystery was one of the least interesting cases yet (if not the most boring in 5 years), so deserves a mere D, and just because I’m feeling generous. The final solution hurt my mind trying to understand, and earns another D. The medicine was scattershot and unenlightening, but not much worse than the season’s average so earns a C-. The soap opera was…adequate, barely. C.

The most damning thing I can say is that there were no great House lines or moments that made me chuckle — for the first time ever.

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

This week’s House Challenge scores have been posted.

After looking at the Worst Comic Book Medicine of 2008 earlier, now I’m going to celebrate the Best Comic Book Medicine of 2008.

Best Depiction of Medicine:
The hospital scenes in Blue Beetle #31.link

Best Doctor:
Doctor Mid-Nite finally got the chance to strut his stuff as the preeminent physician of the DC universe, showing up not just in the Justice Society of America, but also having medical assistance roles in Detective Comics, Blue Beetle, and Terra.

Best Single Medical or Scientific Concept:
Slim pickings again this year, but I’d say the best and most realistic medically-driven storyline this year was Sadie’s marked personality changes after suffering brain damage, as seen in David Lapham’s Young Liars series. link

Best Imaginary Medicine or Treatment:
Warren Ellis’s fascination with super-heroes and polyploidy (additional sets of chromosomes), as seen in both Ultimate Human and his run on Astonishing X-Men. link

Special Mention:
Best New Doctor: Dr. Faiza Hussain, the Excalibur-wielding physician from Captain Britain and M.I. 13.
Best Medically Accurate Art: Rags Morales in Nightwing #148.
Best Technobabble: Mandarin’s scientist in Iron Man #24, when he tried to explain how Maya had disguised the Extremis code by hiding it binarily in protein complexes in the genetic structure..

Previous “Best of the Year”: The Best Comic Book Medicine of 2007 The Best Comic Book Medicine of 2006 The Best Comic Book Medicine of 2005 The Best Comic Book Medicine of 2004

I figured it was time to take a look at Batman: Knightfall, the storyline where Batman has his back broken by Bane, and then begins the process of recovery.

I hope it goes without saying that Batman’s recovery is nothing short of miraculous: in less than two years, he manages to go from struggling to breathe to a full return to crime fighting, none the worse for wear. As the late night infomercials say, “results not typical”.

For the purpose of this post, I’m going to focus on the period initially after the injury where he is under the care of first his faithful butler Alfred, and then neighborhood physician Dr. Shondra Kinsolver.

I. The Injury
To start off, let’s take a close look at what happened to the Dark Knight. There are two mechanisms of injury here. First, Batman’s spine is hyperextended; it’s bent backwards farther than any back is meant to go. Second, Bane is driving his knee into the back, pushing the spine forward.
[click here for an annotated image.]

II. The Doctor’s Assessment

Dr. Kinsolving: These x-rays clearly show a fulcrum-type stress fracture. Not at all the kind of trauma sustained in a car crash.

Dr Kinsolving is both right and wrong.

She’s right in that the way the injury was explained to her (a car accident) does not match the injury she observes (blow from behind). Alfred tries to explain it away, but she’s already suspicious.

However, she’s wrong in the way she herself describes the injury. While Bane’s knee was used as a fulcrum to break Batman’s back, what he suffers is not a fulcrum fracture per se. Those are a type of Chance fracture and occur with hyperflexion (the back bending forward too far), not hyperextension.

It’s not really a stress fracture either. Those can occur in the spine, usually with an increase in repetitive trauma (for instance, athletes who increase their workout), or with trauma. However, stress fractures of the spine don’t occur in the verterbral body, and do not occur with the kind of trauma Batman experienced.

Despite what she says, I don’t seem much of a fracture on the x-ray she’s holding up, unless it’s the diagonal line on the vertebra. If that’s what she’s referring to, it doesn’t match the type of injury she’s describing, or the one Batman suffered. [click here for an annotated image.]

(Based on the mechanism of injury, I’d predict that Batman suffered a fracture/dislocation injury. There was some spinal breakage occurring, but most of the injury is from one or more of the vertebrae being pushed forward into the spinal cord, injuring it).

III. Steroids
Steroids are a good treatment for spinal cord injuries. Bear in mind the term “steroid” generally refers to one of two related, but distinct, classes of medication.
1. There are the infamous anabolic steroids. These are the ones that cause an increase in muscle mass and have been abused in most major sports; Bane’s own drug Venom is a particularly fast acting and potent anabolic steroid.
2. Then there are the glucocorticoids (a type of corticosteroid). These are potent anti-inflammatory and immune suppressing drugs. They are used for asthma attacks, poison ivy, autoimmune diseases and other conditions where it is important to calm down inflammation or the immune system. This is the class of steroid that is used in treating spinal cord injuries; it reduces the swelling and improves the recovery.

Decadron was not developed for or “specifically made” for spinal cord injury. It has many medical uses and was around a long time before anyone thought to use it for spinal trauma.

Additionally, it is not a controlled substance and is easy to obtain with a prescription. We have a large supply in a drawer in our office. I suspect the writer is confusing it with an anabolic steroid — which is a controlled substance.

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 enjoyable episode of House; one of the better of the season. A good mystery, and the medicine was generally decent. Some nice battle of wits soap opera as well.

Emmy, a thirty year-old fitness instruction, is filming an infomercial when she experiences sudden difficulty breathing and collapses, breaking her ankle in the fall. She is admitted to House’s service for evaluation and all the initial tests were normal. Taub suspects her of steroid use, Kutner mentions environmental allergies, and Cuddy suspects exercise induced asthma. The last seems the most likely, so the team sets about to recreate Emmy’s episode, the best they can with her broken ankle. Sure enough, while in the middle of exercising, she once again collapses and is found to be pulseless.

Kutner suggests she may have Carcinoid syndrome. A CT is obtained which shows no carcinoid tumor, but does reveal that she has had gastric bypass surgery in the past. This catches the team by surprise, and has them rethinking their differential diagnosis: now diabetic neuropathy (nerve damage caused by diabetes) and sleep apnea are added. Thirteen suggests gastrointestinal malabsorption leading to a low potassium, but Kutner takes it one step further and thinks Emmy may have SIBO (small intestine bacterial overgrowth) in a blind loop of bowel, and that these bacteria are making their way into her blood stream causing her symptoms. They test her stool, but there is no evidence for bacterial overgrowth or fat malabsorption.

House decides to rethink sleep apnea, and has Kutner and Taub run a sleep study. During the test she sneaks out, and the pair find her exercising on a treadmill, her ankle still in a splint. They also notice she is bleeding from the ankle and never noticed — she has lost sensation in her foot. The differential now includes multiple sclerosis, Parkinson’s Disease, and transverse myelitis (a crosswise inflammation of the spinal cord). House orders a nerve conduction velocity test (NCV), but while setting it up, Taub realizes that she is losing muscle strength in her arms. This again changes the differential, and the team considers myasthenia gravis, botulinum toxin exposure, other toxins, or heavy metal poisoning. House has them start her on chelation to treat her suspected heavy metal toxicity, but there is no change in her condition. The latest differential consists of a corornary-cardiac fistula (an abnormal connection between the coronary arteries — which supply blood to the heart muscle — and the interior of the heart), Austrian syndrome (meningitis, pneumonia and endocarditis caused by the Pneumococcus bacteria), or Guillain-Barre Syndrome (an autoimmune disease of the peripheral nervous system). The latter fits the symptoms the best, so she is started on the treatment for Guillain-Barre, plasmaphersis.

When Emmy starts hallucinating, the team realizes that the Guillain-Barre diagnosis is wrong as well. Thirteen favors a diagnosis of CNS lymphoma, but Taub is suspicious she has a prion disease (a rare type of disease caused by infectious protein particles. The best known example is probably mad cow disease). House wants a brain biopsy, but Cuddy won’t let him until they’ve ruled out other brain tumors by non-invasive means. The initial tests come back negative and House decides to perform the brain biopsy himself. However, when he and Taub enters the room, they find Emmy up and about, feeling good. Taub informs House that there have not been any new drugs, but that she did eat a piece of chocolate cake from the cafeteria. House now realizes the cause of her condition — she has hereditary coproporphyria. This is an inherited disease that House tells her can be controlled by a high carbohydrate diet. When she was fat, she ate that type of food all the time, so suffered no ill effects, but now that she is slender and eating healthy, the symptoms have caught up with her. He recommends resuming the high carbohydrate diet, but she chooses to continue her low calorie diet and take medication to control her symptoms.

Major complaints are in red, minor in blue, nit-picking in green. Overall, not too many big errors this week, but many of the diagnoses were quite a stretch.

You don’t test for SIBO with a stool study. You need an aspiration of fluid from the small intestine to evaluate or a hydrogen breath test. Plus, if she has a blind loop of bowel, how are the bacteria from it going to end up in the stool to be tested?

She was pulseless, but they never specifically said what her rhythm was. If it was asystole or PEA, then defibrillation was wrong. Otherwise, it was probably right. (And I’m still not too clear on why she coded in the first place).

The time course was off again, but in different way than usual. Emmy must have been several years out from her surgery — she had the weight to lose, the muscles to tone, the fitness guru-ness to obtain, and the informercials to produce and distribute — and only now does she start to have symptoms?
And she never had symptoms with a low carb diet while trying to lose weight before her surgery.

Diet alone is not the best treatment for severe CHP attacks. A drug known as Hemitin also helps.
A high carbohydrate diet is recommended by some physicians. Most doctors recommend a healthy balanced diet with high carbs only during acutre attacks.
Abdominal pain is a key symptom of coproporphyria.

Several episodes this season where diagnoses are made by looking at the urine color and they miss the classic purple urine in this one?

The medical mystery was good this week and deserves an A. The final solution was fairly clever, though a bit of a stretch, and earns a B. The medicine, though again quite a stretch at points, was good overall and also earns a B. The soap opera was well done, both in terms of House/Cuddy and Thirteen. I give it an A, with extra credit for Cuddy’s comment about House’s balls.

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

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

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

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

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

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

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

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

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

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

Once again, you do not shock a flatline.

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

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

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

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

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

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

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

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

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

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

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

Read more…

A fairly ho hum episode of House, with far too many red herrings and not enough real medicine.

Brandon is, at best, a mildly successful artist. At the beginning of the episode, he is painting a portrait of a woman, but when the woman and her husband take a look at the finished product, they are shocked because the subject in the painting is horribly distorted. Even stranger is the fact that Brandon cannot tell that anything is wrong; the portrait looks completely normal to him.

Brandon is admitted to the hospital for evaluation of his acute onset visual agnosia. The initial differential diagnosis include stroke, brain tumor, drugs, or environmental toxins. An initial MRI was negative, but House wants an MRI with contrast. He also sends Taub and Kutner to search Brandon’s apartment for toxins. The search turns up nothing suspicious and the MRI is negative.

Toxins and drugs remain on the differential diagnosis, but a cavernous angioma of the brain (large, abnormally dilated blood vessels in the brain) has been added as well. When Brandon shows little emotion when told he requires a risky surgical biopsy, House deduces that he is hiding something. It turns out that he has had to make ends meet by enrolling in clinical trials of new drugs. He is currently a participant in three separate drug trials. House assures him that his symptoms were due to the experimental drugs, and since they should be out of his system by now, he’ll be discharged in the morning.

As usual, being discharged from Princeton Plainsboro is a sign of problems to come, and Brandon has a sudden seizure. By now, the team has discovered what drugs Brandon was being given: an anticoagulant, an autoimmune drug, and a statin (a cholesterol medication). They suspect the interaction of all three drugs is causing his symptoms and House elects to give him dialysis to clean all the drugs out of his system. It seems to work at first, but then Brandon develops massive swelling of the tissues of the head and neck occluding his airway. Foreman performs an emergency tracheotomy and Brandon is started on steroids. The differential now includes a thrombosis, Chagas disease (both of which would block the venous drainage, causing swelling), infection, or cytokine storm, with the team favoring the latter. House and the team are unsure whether the cytokine storm is a withdrawal symptom from the experimental drugs, or a new symptom entirely. To solve the puzzle, House elects to put Brandon back on all three drugs, and then wean them off slower this time.

Once again, withdrawing the drugs seems to work at first, but then it becomes obvious that Brandon’s libido has been put in overdrive. A punch to the nose from Dr. Thirteen solves that problem, at least temporarily, but it is a new symptom to consider. Kluver-Bucy Syndrome (a condition caused by damage to both temporal lobes of the brain) is suspected, and an MR Angiogram is obtained to get a closer look at the blood vessels. It shows some narrowing of the vessels of the Circle of Willis (the main arteries supplying the brain). That should not be enough to cause symptoms, but Taub suspects there may an underlying cardiac arrhythmia that worsens them. An EP study (electrophysiology study — it looks for abnormal conduction in the heart) is ordered, and is decidedly positive. During the test, Brandon goes into ventricular tachycardia and needs to be defibrillated. At this point, House notices that Brandon’s hair is turning red around the temples.

Kluver-Bucy is abandoned and Waardenburg Syndrome is suggested, but when Kutner notices a prolonged QT on the EKG (a potentially dangerous heart rhythm), the suspicion shifts to Romano-Ward Syndrome (a common inherited form of Long QT Syndrome). A cardiac sympathectomy (a surgery that reduces the effect of the sympathetic nervous system on the heart) is ordered. When Brandon once again develops visual agnosia, Taub begins suspects the symptoms may be due to lingering toxins, and seeks out Brandon’s old paintings. The paintings show the same distortion every other month — the same time he was on all three experimental medications together. It turns out that in a previous research project, Brandon had been on an experimental antacid which allowed the formation of a bezoar in his stomach. This bezoar trapped many of the experimental pills and has slowly been releasing them, causing Brandon’s symptoms even though he has not been taking any new medications (which means the team had it right halfway through, it was the combination of the experimental drugs, and the last half of the episode was spent chasing one red herring after another. After all, who can argue against the symptoms of “experimental drug reaction”?) The bezoar is removed surgically and Brandon should be good as new.

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

Romano-Ward is NOT caused by five separate gene mutations. It is caused by a mutation in any ONE of five (actually six) particular genes.

That’s a weird type of agnosia Brandon is experiencing, if it’s agnosia at all. He seems to recognize people and things (at least initially), but can’t paint them – which makes it more of an expressive aphasia than an agnosia. Later on in the show, it shifts entirely and he now can’t recognize people he should, which is a type of agnosia.

None of the neurological syndromes or conditions the team mentioned fit the pattern, but again, why have a logical pattern when it can all be explained away with “experimental drug reactions.”

The standard treatment for prolonged QT interval (including Romano-Ward) are beta-blockers or an ICD, treatments that Brandon can’t have, with no good explanation given as to why.
A sympathectomy is a legitimate treatment for prolonged QT syndrome if the beta-blockers and ICD fail

Why is Taub, a plastic surgeon, running an EP study? It requires not just a cardiologist, but a specially trained cardiologist.
But he’s better than Kutner. Shocking v-tach at 60 and then 120? Wrong.

Most phytobezoars can be non-surgically removed (91% by a recent study).

With swelling of the mouth and pharynx, a standard intubation is difficult, so a tracheotomy makes more sense this week. The procedure was surprisingly smooth for a patient that swollen (no landmarks) and for a doctor who doesn’t do them regularly.

Once again, no eye protection during surgery.

The medical mystery was moderately interesting, though annoyingly inconsistent, so earns a B-. The bezoar was clever, but the final solution relied too much on mysterious experimental drugs and their interactions rather than actual potentially-interesting medicine, so only earns a C-. Most of the medicine was flawed, and the rest “experimental”, but it was still better than last week so earns a D+. The soap opera was better. The Taub part was good, House’s names for the experimental medications were fun, but I didn-t buy any of the Cuddy/PI/House interactions. I give the soap opera a C+.

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I’ve discussed commotio cordis a couple of times, most recently in relation to Batman #672-674.

Commotio cordis is a rare and frequently fatal condition. It occurs when an individual receives a direct blow (blunt trauma) to the chest at precisely the right time in the cardiac cycle to stop the heart and cause a cardiac arrest. Children are more susceptible to the condition than adults.

Sports injuries are a common cause of commotio cordis, particularly thrown baseballs and softballs. Other causes include physical blows to the chest during a fight, steering wheel impact in motor vehicle accidents, and even the blunt force of bullets stopped by body armor.

The best, and really only, treatment for commotio cordis is immediate cardiopulmonay resuscitation, usually requiring defibrillation and cardiac medications.

Wikipedia has a good write up on commotio cordis

Commotio cordis has been in the news recently because of a lawsuit filed by a New Jersey family against several groups: a maker of aluminum baseball bats, the Sports Authority*, and Little League Baseball**. It’s an unfortunate story on many levels: Twelve year-old Steven was pitching in a baseball game when a line drive hit by the batter caught him square in the chest, causing his heart to stop beating. He was eventually revived, but remained in a coma for several weeks, and now has severe brain damage.

It’s a sad story and an unfortunate case, but personally I think it’s a stretch to treat it as cause for a lawsuit. I know that we Americans always like to blame someone when something goes wrong, but there are times that it’s not appropriate. This is one of those times.
There is no hard evidence that aluminum bats are any more dangerous than wooden ones, particularly in cases of commutio cordis (remember, it’s an issue of timing, not an issue of force).
There is an inherent risk of injury in playing any sport. Proper safety precautions will minimize this, but never eliminate it entirely. I am well aware of this whenever I go for a bike ride on the back country roads near me. Who knows what drunk-driving redneck may be out there weaving across the center line?***
And suing Little League because they endorsed the bat? Give me a break.

*The store where the bat was purchased
**Not because it was a Little League game — it was not — but because they “endorsed” the bat as safe.
***It would be like me, after getting hit by a reckless driver, suing Ford because the person was driving a Mustang and those can go faster than other cars. It may be true (arguably), but it really has nothing to do with the accident and injury.

The season finale of season four of House. The medical aspect remained spotty, but this was primarily a character episode, so how much you liked it is probably determined a great deal by your personal tolerance for schmaltz.

House and Wilson find Amber across town, admitted at another hospital. She is in bad shape after the bus accident. She completely damaged both kidneys in the accident and needs dialysis. She also has an elevated heart rate. Despite this, House feels that she would be better served at Princeton Plainsboro Hospital and convinces Wilson to pretend he’s Amber’s husband so that he can get her transferred. On the ambulance ride, Amber slips into ventricular fibrillation. House prepares to defibrillate her, but Wilson stops him, feeling the chemicals released by the heart after the defibrillation will cause brain damage. Instead, he convinces House to put Amber on a heart-lung bypass machine in “protective hypothermia” to buy time so that he can figure out how to save Amber.

The initial differential diagnosis for Amber’s condition is an autoimmune disorder, a congenital heart defect, blood clotting disorder, and lead toxicity. House orders an angiogram, and orders Kutner and Thirteen to search Amber’s apartment. Taub decides to order a drug screen. House has a hallucination about Amber puring him some sherry (which Kutner interprets to mean Sherrie’s Bar); he also considers deep brain stimulation to recover his missing memory of the night in question. These ideas are dropped for now, but surface again later.

Both the angiogram and drug screen are negative. Searching Amber’s apartment, the team turned up some prescription diet pills. They conjecture that these might have injured Amber’s mitral valve, leading to her heart problem. Because her heart is stopped, they can’t check a CT scan, so instead House wants the team to crack open her chest and stick a finger in the pulmonary artery to check the valve.

As Chase is setting up the surgery, he notices that her eyes are icteric (jaundiced), a sign that she now has liver failure. Antitrypsin deficiency is suggested as a possible cause and a liver biopsy is ordered. Wilson feels that since the condition is progressing, Amber needs to be cooled further. Reluctantly, House agrees.

House and Wilson talk to the bartender at Sherrie’s and learn that Amber was sneezing. House considers a parasitic infection at first (it’s quite a stretch, but not as bad as the “cancer” diagnosis for an itchy nose last week), then decides the most likely cause of Amber’s symptoms is Hepatitis B. The liver biopsy seems to agree with this diagnosis and she is started on interferon. House heads home to try to catch up on sleep and has a dream about Amber and the small of her back. He returns to the hospital, and sure enough, she has a fine red rash on her lower back (so much for a good physical exam on admission). The possible causes of the rash the team considers are influenza, dermatomyositis, an allergic reaction, abscess, or Rocky Mountain Spotted Fever. This last one seems the most likely, so House and Foreman want to start her on doxycycline to treat the infection and then warm her up and restart her heart. Wilson wants to wait for confirmatory cultures first, but this will take much longer. House agrees with Foreman, but Wilson managed to guilt him into waiting for the cultures. Foreman goes to Cuddy, and she agrees that Amber needs her heart restarted sooner rather than later. Wilson walks in while they are rewarming her and freaks out. He notes that her brain waves show slowing so her condition must have spread to the brain and he blames Foreman and Cuddy.

With heart, lung, liver, and brain involvement, an autoimmune disease is the most likely cause. House plans to start Prednisone. Wilson reluctantly agrees, but wants House to undergo deep brain stimulation first, so that he can remember more of what happened the night of the bus crash. Undergoing the procedure, House recalls Amber sneezing several times and complaining about having the flu. He then notices her taking several pills. He determines that she has been taking Amantadine for the flu, and because her kidneys have been severely damaged, the drug has not been cleared and has built up to toxic levels, causing the other symptoms. Unfortunately, dialysis doesn’t work on Amantadine and the toxicity is irreversible — meaning that Amber is going to die. House passes on the sad news to Wilson just before he suffers a massive seizure from the brain stimulation. Wilson wants Amber to pass away without ever waking up, but Cuddy convinces him to wake her up so that they can spend a last few minutes together. He acquiesces.

Meanwhile, House is in a coma. The seizure reopened his skull fracture causing a bleed on his brain. He has a dream/hallucination featuring the now dead Amber, but then slowly returns to consciousness. As the season ends, House wonders if Wilson will ever forgive him for his part in Amber’s death.

The medicine was, like recent episodes, sloppy — but it didn’t seem as haphazard as the last few weeks, probably because they focused on just 3 or 4 diagnoses over the course of the episode.

The writers are correct in that Amantadine is poorly cleared by dialysis, and there have been deaths reported on the medication. The dose for the flu is 100MG twice a day. The only size pill Amantadine comes in is 100MG, so Amber taking two means that she was overdosing herself on it, so she bears some of the blame for this.

What happened to Amber ventricular fibrillation? Did she really remain in v-fib all the way to the hospital until she was cooled? That’s unlikely. Plus, the longer she remains in v-fib, the longer the nasty chemicals Wilson was worried about will build up. Defibrillating early is still the best shot.

Heart-lung bypass and “protective hypothermia” don’t work like that. They’re designed for short-term use, like surgeries. They are rarely used longer, for transplant patients for example, but you don’t keep cranking down the temperature.

The mitral valve is not in the pulmonary vein; it’s in between the left atrium and ventricle. Unless House is suggesting sticking a finger through the pulmonary vein, and then into the heart itself to reach the mitral valve. That’s a disaster waiting to happen. And how is sticking a finger in a major vein a good idea? How are you going to get the finger in there without cutting a big hole in it?

“Diet pills don’t cause jaundice,” that may be true, but blunt trauma does cause liver damage -– like from, I don’t know, a bus accident that destroyed both of her kidneys.

Even if deep brain stimulation could restore memory (and I see no indication in the medical literature that it can), there would be no way to target a specific memory. It’s also performed under general anesthesia (the patient is asleep) [UPDATE - Not necessarily; see the comments], and the results are not instantaneous.

That wasn’t a complex partial seizure House suffered, that was a gran mal (tonic clonic) seizure.

The medical mystery was good, and the ultimate solution clever (and mostly correct), if depressing, so both earn an A-. The actual medicine was — discounting the heart lung bypass/hypothermia — above average, but that bypass and hypothermia dragged it back down to an average C. The soap opera was powerful, if a little overwrought in the end for my taste, but still earns a strong A-.

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Continuing my look at Mike Carey’s and Scot Eaton’s X-Men – Legacy #209. (Part one can be found here.)

In this scene, Frenzy confronts Magneto and the recently revived Xavier. She plans on killing Xavier, but Magneto has other ideas — not to mention a conveniently near surgical laser.

Click here to read the full scene

Xavier: He’s thinking about your eyes
Frenzy: What?
Xavier: And — your optic nerve. Because for your eyes to see, the channel has to stay open all the way into your brain.

At first read, it sounds like Xavier is implying there is “channel” into the brain that is only open when a person is actively using their eyes, or maybe he’s suggesting that the optic nerve will transmit the laser like fiberoptic cables transmit light. Neither is correct.

However, after repeated reading, I think I know what Xavier’s trying to say in his own horribly wordy way. I suspect that he’s merely suggesting that Magneto will use the laser to essentially lobotomize Frantic by shooting the beam through the optic canal into the brain. The optic canal carries the optic nerve and ophthalmic artery from the eye socket to the brain pan. This will damage the optic nerve (rendering her blind — at least in one eye) and cause brain damage. But it sure is an awkward way to phrase it.

It would be a tricky shot too, as the optic canal is located off to the side of the eye socket and proceeds inward at an angle; it’s not the straight shot the art suggests. That’s also a pretty good range for a surgical laser (and note the significant change in the drawing of the laser between the panels. Initially, it’s hand held — like a thick pencil — but by the last panel it suddenly is drawn like a laser pistol).

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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Batman #672, #673, and #674 “Space Medicine,” “Joe Chill in Hell,” and “Batman Dies at Dawn” Grant Morrison, writer Tony Daniels, penciler Batman is shot point blank in the chest by the mysterious “Third Batman” (a police officer once trained to take Batman’s place if he were to die), which causes his heart to stop. Batman collapses, but is later revived when the Third Batman shocks his heart back into a normal rhythm. At this point, Batman exclaims: “My God — I had a heart attack — on the roof of the GCPD — “ There are a handful of problems with this scenario: #1. There is a difference between a cardiac arrest and a heart attack. A cardiac arrest occurs, as the name suggests, when the heart (cardiac) stops beating (arrest). Cardiac arrest can be caused by several different conditions, including a heart attack, an abnormal heart rhythm, trauma, and electrolyte abnormalities. A heart attack (”myocardial infarction” in medical-ese) occurs when one or more of the small arteries supplying the heart with blood are suddenly blocked and the heart can no longer obtain the oxygenated blood it needs to survive. The affected part of the heart muscle (myocardium) then dies (infarcts). If a large enough part of the heart dies, it can lead to a cardiac arrest and death, but it is certainly possible to have a heart attack without suffering a cardiac arrest. In the story, despite what he says, Batman suffered a cardiac arrest, not a heart attack. He developed an abnormal heart rhythm that degenerated into asystole (a flatline). This abnormal rhythm was brought about by direct trauma to the chest, a kind of commotio cordis (a condition which occurs when a blunt trauma to the chest happens at just the right instant in the heart cycle to disrupt the normal heart rhythm and cause a fatal arrhythmia and cardiac arrest. It is most common in children, and is thought to kills several Little Leaguers struck in the chest by baseballs every year. There have also been recorded cases of commotio cordis occurring in adults struck by a bullet who were wearing body armor, much like Batman in this situation). #2. After Batman slipped into asystole, he was brought back by the Third Batman using a defibrillator. I know I’ve covered this many time before, so everyone repeat after me: you don’t shock a flatline. It’s a bad idea — especially after several minutes of asystole have elapsed, as in this case. (Though Morrison is right that brain damage after a cardiac arrest starts at the five minute mark.) #3. The Third Batman appears to have defibrillated Batman through his uniform, which I always understood to be insulated. Or else he defibrillated him through the hole blown in his uniform, which would put the paddles in the wrong position to work. The art in the book actually suggests he defibrillated the right side of the chest (the wrong side), so I’m giving Daniels the benefit of the doubt and assuming he’s showing the moments leading up the actual defibrillation, as the Third Batman moves the paddles into position. Tags: comics medicine batman cardiac arrest defibrillation commotio cordisgrant morrison tony daniels

Young Liars #1 “At a Thousand Miles an Hour”
David Lapham, writer and artist

Today, I’m going to talk about brain injuries and personality, primarily focusing on Sadie, one of the main characters from Young Liars #1. Sadie suffered a bullet wound to the brain which did extensive damage and has led to an extensive change in her personality, including increased aggression, lack of social restraint, and inappropriate sexual behavior.

According to the doctor, Sadie suffered injuries to the “moral and emotional centers of her brain,” including:
1. Cingulate Gyrus/Limbic System
2. Frontal Lobe
3. Temporal Lobe
4. Amygdala
5. Hypothalamus
He also mentions that — at some point in the future — the retained bullet will sink lower in brain and damage the brainstem, killing her.

Overall, I’d say that Sadie’s personality changes are consistent with the brain damage she has suffered, particularly the damage to the frontal lobe. (For the record, I’m a little doubtful of her doctor’s suggestion that the “bullet will eventually drop and damage the brain stem” — but if it does occur, he’s right that it would be fatal.)

This topic suggested by Douglas Wolk over at the Savage Critics.

Tags: comics medicine young liars brain damage cingulate gyrus frontal lobe temporal+lobe amygdala hypothalamus limbic system

The official start of the 2008 NASCAR season, the Daytona 500, is this weekend, so I thought it would be a good idea to look at issue #2 of the NASCAR Heroes comic book.

I believe this second issue of NASCAR Heroes is actually slightly better than the first one, but that’s not really saying much. The story picks up right where the first issue left off. Dashiell James, a lowly janitor, and his friends of Team Flatrock were caught in a mysterious explosion caused by the evil rocket scientist and top NASCAR racer Jack Diesel (yes you read that right, not only is Diesel NASCAR’s #1 driver, but he’s also a rocket scientist). The mysterious radiation from this explosion gave everyone involved super-powers. Dashiell uses his powers to become the mysterious masked racer “Jimmy Dash” and he and Team Flatrock have become Diesel’s biggest competition.

Most of the book is taken up by various races between Diesel and Dash which all follow the same pattern: Diesel uses his super-powers in an underhanded way to attack Dash and his car, yet Dash somehow manages to beat him in the end. For instance, Diesel — while driving at competition speeds — leans his entire upper body out of his car window and physically tears a chunk of Dash’s car away and rips through an oil line, or maybe it’s a brake line. Regardless, Dash is able to bring his car down pit lane and stop it with feet through the floor board, a la Fred Flintstone. His team manages to fix his car with some bodywork and a new belt for the water pump (how that fixes brakes or an oil line, I don’t know). Dash and his car race back to front but this time Diesel shoots a laser beam from his eyes at them. Luckily, Dash is ready and raises a mirror he has prepared for such an occasion and reflects the laser back at Diesel (yes, his reflexes are apparently faster than light). Using this distraction, he is able to win the race.

I’m beginning to think that the poor logic in the book’s storytelling may actually cause brain damage. As far as you can tell by the story, there are only two cars at each race. Never mind the other 41 cars, drivers, teams, track personnel, NASCAR officials, reporters or sponsor representatives that should be there. Somehow the NASCAR officials never seem to notice such minor things as laser beams, spurting oil, or drivers leaning out the window and never ever call a caution. The most spectacular display of illogic occurs toward the end of the comic when Diesel holds Team Flatrock’s owner Astor hostage at a local auto salvage yard; he tells Jimmy Dash to meet him there alone. To his credit, Jimmy comes with the other members of the team. On the other hand, they all come in the team’s single race car: a not-road-legal race car that can barely manage to hold one person yet somehow manages to carry the entire team. Plus, you know, it’s an auto salvage yard — bringing a race car there is just asking for trouble.

The art tries, but is mostly amateurish (one problem may be the fact that the credits list one main artist plus four additional “guest artists”). It’s not bad, but it needs to be a lot better in what is supposed to be a professional comic. The layout and blocking are good and show an understanding of the comics medium, but the colors need a lot of work and always come off looking flat.

On the plus side, there are imaginative use of sound effects. In this issue, we get a Bzannnnng, a bunch of Krimps, several Ftashes, a Zavf, plus the ever reliable Wump, Klang, and Klunk. The paper quality is nice, too.

The main problem with this comic is the same thing that I mentioned after reading the first issue: it doesn’t know what it wants to be. Is it a NASCAR comic for comic fans, or a comic book for NASCAR fans? It tries to be both, and succeeds at neither. The story is too over the top and too cliché to appeal to modern comic readers (and it’s probably even too much for Silver Age readers — and that says a lot). On the flip side, the racing scenes and background are too far removed from the reality of the sport to appeal to the NASCAR fan.

Tags: comics nascar nascar heroes

In my previous discussion of brains and comic books, I neglected to mention a key concept: The Kryptonian Brain Cell Transplant.

It all starts when Linda Danver’s boyfriend David jumps into a swimming pool to save another swimmer, but strikes his head on some underwater debris, suffers brain damage, and falls in a coma.

Supergirl, of course, realizes that just because “no power on earth” can save David doesn’t mean that no one can. She rushes off to the Fortress of Solitude to talk with the scientists from the bottled city of Kandor, certain that Kryptonian science can save her boyfriend (along the way, she rationalizes that she and Superman only turn to the Kandorians in the direst of emergencies¹). Eminent Kandorian scientist Professor Ron-Kar tells her that only a Brain-Cell Transplant can save David.

The Professor arranges for Supergirl to obtain the Kandorian surgical equipment necessary to perform the transplant (made of Quasi-energy, so that only Superman or Supergirl can use them²). Supergirl first uses the tools on herself to obtain “thousands of super-brain cells”, and then transfers them into David (you’ll also note that the Professor falls victim to the 10% Myth here).

The operation is a success and David survives! Unfortunately, he’s not quite what he appears. Instead of being an ordinary graduate student, he is instead a criminal gang leader masquerading as a graduate student for cover. He’s dating Linda not because he cares for her, but because he thinks she’ll make a good alibi for him (poor Linda/Supergirl, she never could find a good date). He discovers that the brain cell transplant has not only saved his life, but also granted him superpowers just like Supergirl. He puts on a lead mask³, calls himself the Super Scavenger, and robs a bank. Supergirl quickly catches up to him.

They battle, but David’s super powers are only temporary (much like Superman’s blood transfusions), and Supergirl is able to capture him and turn him over to police. But there goes her date for the weekend…

This medical case study comes from the the physicians at the Vandyre Clinic, Kandorian Professor Ron-Kar, and Supergirl #4 (by Bates, Saaf, and Colletta)

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Notes:
1. This is a little ironic coming from Supergirl who seems to call on Kandor for help every other issue. She has an awful lot of dire emergencies — most of which seem to revolve around boys.
2. Which doesn’t explain why the Kandorians have them or how they use them since they don’t have super powers.
3. He wears the mas so Supergirl won’t be able to figure out who he is. While she may be unable to see through the mask, she is able recognize David’s watch. Today’s take home lesson for would be super-villains: avoid over-accessorizing.

Tags: comics medicine brains supergirl transplant kandor

House lands the prime post-Super Bowl slot, and it was a strong episode overall. The medical mystery was intriguing, as were the logistical difficulties involved in solving it. There were some strong character moments, and a surprise reveal at the end that I did not see coming.

The medicine? Eh, it was OK. The rest of the show was good though.

Cate is a psychiatrist working at the South Pole on a psychological research project, as well as serving as the physician for the team stationed there. Just after treating another staffer with an injured femoral artery, she develops sudden intense right-sided flank pain, vomiting, and begins gasping for breath. No other physicians are available at the South Pole and evacuation is not an option. Since Cate is an adjunct faculty member at Princeton-Plainsboro Hospital, the Psychiatry Department asks House to treat her. Given her location, all the diagnosis and treatment must be done over webcam, and the medical supplies and tests available at the South Pole are minimal.

The initial differential diagnosis includes appendicitis, gallstone, or kidney stone. House in particular feels she has a struvite kidney stone due to recurrent urinary tract infections (large and jagged kidney stones that form due to urinary infections). She denies any history of urinary tract infections. Her Chem 7 (also known as a Basic Metabolic Panel, or BMP) shows declining kidney function, which House believes proves the existence of a kidney stone. He wants her to take a dose of intravenous Cefuroxime (a broad spectrum antibiotic) to cover any infection. She declines, telling House that there are other people who may need their limited supply more. Her kidney function continues to decline. House continues to believe this is a kidney stone, but she believes it is because of dehydration from the vomiting (and dehydration can certainly alter kidney function tests, though it usually has a very specific pattern); she wants to repeat the test after she’s rehydrated. In the middle of the conversation, she becomes tachypneic (rapid breathing) and develops chest pain. House notices that her trachea is deviated to the left which means that she has a tension pneumothorax, a life threatening emergency. Under his direction, she is able to relieve the tension by performing a needle thoracostomy (basically inserting a needle into her chest to relieve the pressure and allow the lung to re-inflate).

The differential now includes tuberculosis — but her PPD was negative, as was everyone else’s at the South Pole — and cancer in the kidney or lungs. An x-ray of her body shows an enlarged mediastinal node which could be a sign of lymphoma. Unfortunately, it is too deep for anything but a surgical biopsy, and that’s not an option. No other lymph nodes show up on x-ray (but then, x-rays aren’t very good at showing lymph nodes), so House has her perform a detailed physical exam on herself to look for other nodes, closer to the surface. She finds an enlarged node just above the belly button. Under Wilson’s direction, Cate plunges a syringe into it and withdraws about 2cc of a straw-colored fluid. No cancer cells show up in the fluid, but there are signs of inflammation. Unfortunately, Cate now begins having severe left flank pain, identical to what she had earlier on the right.

House suspects an autoimmune disease such as SLE (lupus) or vasculitis. He wants to start her on Prednisone, but she doesn’t want to use the medication unless she knows for sure that it’s an autoimmune condition. Foreman states that the normal test, an ANA, is not available, nor is an older test looking at C3. They can perform an improvised LE Prep (Lupus Erythematosus Cell Preparation). The test result is negative, arguing against an autoimmune condition, but House is still suspicious. Reluctantly, he agrees to Foreman’s plan to have Cate go outside, on the theory that the extreme cold will reduce the inflammation of the autoimmune disease and reduce her symptoms. She is about to comply when she passes out and then slips into a coma.

House, Foreman, and Wilson are now dealing with the station mechanic, as Cate is in a coma. They have him taste her urine to see whether it is concentrated (suggesting a kidney problem) or dilute (suggesting a brain problem). The urine is watery, so the cause of Cate’s coma is likely in her brain, they suspect an elevated intracranial pressure (ICP) or a hypothalamic problem. Under the team’s instructions, the mechanic drills a burr hole into Cate’s skull. This is to relieve any increased ICP. Sure enough, she comes out of her coma shortly after the hole is drilled.

House’s team now considers what condition could cause kidney problems, lung problems, and increased intracranial pressure. The differential includes tumor (already ruled out), bacterial endocarditis, deep vein clots, atherosclerotic emboli or fat emboli. House is intrigued by this last suggestion. Cate was cold during the exam and had left her socks on. When they are removed a broken toe is revealed. This broken bone has been throwing off clots of fat to the kidney, lungs, and heart, causing her problems. The bone is reset and splinted and she should be fine.

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Fat emboli can definitely cause lung problems in the form of pulmonary embolism (clots to the lungs), but I don’t see any way it cause a tension pneumothorax. In terms of the treatment of Cate’s tension pneumothorax, the needle thoracostomy relieves the tension aspect of the pneumothorax, but a simple pneumothorax still remains. Cate needs a chest tube (or if it’s small enough, 100% oxygen — all the time, not just an occasional breath).

That’s not how a percutaneous needle biopsy is performed, and that’s an incredible amount of fluid to get back — it’s a solid tissue structure they’re biopsying, not a cyst. PLus, I find it hard to believe the medical kit wouldn’t contain a local anesthetic such as Lidocaine.

Sending someone with an autoimmune disease or vasculitis out in the cold is not a clever idea. It may reduce their symptoms, possibly, if the moon is right. Or it could cause a bad case of Raynaud’s Disease (a cold-induced spasm of the blood vessels in the fingers and toes. It is common in people with autoimmune diseases and vasculitis).

I can see how a fat embolism in the brain could cause a coma (from causing a stroke), but I don’t know that it would increase the intracranial pressure and cause a coma that way.

How did fat embolism lead to enlarged lymph nodes?

It’s fractures of the long bones (femur, most commonly) that lead to fat emboli. I don’t think there’s enough fat in a toe bone to cause a fat embolism.

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I give the medical mystery an A because it was the best mystery they’ve had in a while. The limitations imposed by the patient being at the South Pole were well done. The final solution fit the big picture (lung, kidney, and brain damage), but missed the specifics (how did clots do all that? And from the toe?) so gets a merely mediocre C-. The medicine was for the most part appropriate, especially given the limitations already mentioned. The final answer is where the medicine fell apart. Still, I’ll give it a B- overall. The Three Musketeers didn’t add much this week, but Wilson and special guest patient Cate more than made up for them. That Wilson-is-dating-who? ending is worth some points as well. A for the soap opera.

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Tags: television medicine house kidney stone cancer autoimmune

A mediocre episode tonight. There were several good ideas (the facial deformity, the documentary crew), but it never gelled into a good episode. The medicine was spotty and the soap opera focused too much on a few characters instead of spreading the wealth.

Kenny, a sixteen year-old boy with a prominent facial deformation has arrived at Princeton-Plainsboro Hospital for reconstructive surgery. A documentary team is trailing behind, filming everything. As Kenny is being prepped for the operation, his heart rate shoots up and he goes into ventricular fibrillation. This requires defibrillation and the placement of a pacing wire to get his heart beating normally again (a temporary external pacemaker is being used to restore a normal heart rhythm). He is admitted to House’s team for the work-up of his heart problem.

The initial differential diagnosis includes increased intracranial pressure, a congenital heart defect, or endocarditis. House dismisses all these. He has noticed some darkened skin under Kenny’s nose (identified as acanthosis nigricans) and suspects that he has been inhaling (”huffing”) Freon, which has damaged his heart. He orders a nuclear study (a test which uses a radioactive dye or marker) to look for scarring in the heart. The nuclear study is essentially negative, and Dr Taub (the plastic surgeon candidate) suggests that Kenny might have Toxoplasmosis and he wants to perform a lumbar puncture. House points out that Taub doesn’t really think that Kenny has toxoplasmosis, he just wants to do the lumbar puncture to check the intracranial pressure; Taub admits as much. House still thinks that Kenny has been doing drugs and orders an EP study (an electrophysiology study is one that uses tiny catheters to look for and treat abnormal rhythms in the heart). Dr. Taub starts the EP study, but stops when he determines that Kenny has never used drugs. About this time, Kenny starts coughing up blood.

The differential is now a Mallory-Weiss tear (a bleeding rip in the esophagus from prolonged coughing or vomiting), a nasal papilloma, a peptic ulcer, nasopharyngeal angiofibrosis, stomach cancer with paraneoplastic syndrome, or liver failure. An EGD is performed which shows no stomach cancer, but does show bleeding varices (distended veins of the esophagus), which go with liver failure.

Dr. Terzi suggests an autoimmune disease like Scleroderma, but is shot down. A mitochondrial disorder is suggested as well, and Dr. Taub continues to think that Kenny has increased intracranial pressure. His retinas are examined. They show no degeneration (said to be a sign of mitochondrial disease), but do show papilledema (a type of retinal swelling — a sign of increased intracranial pressure). When informed of this fact, House points out that Kenny’s skull deformity gives him an increased intracranial pressure and he’s lived with it all his life so House doesn’t think this is the problem. Instead, he suspects JRA (juvenile rheumatoid arthritis) and wants to start Kenny on steroids. There is a dust up between Taub and House and Cuddy ultimately gets involved. A head CT is obtained. House believes that is shows signs of JRA, while Taub thinks it shows something different. Cuddy sides with House and steroids are started. Taub is fired (but told not to leave).

Kenny shows some signs of improvement on the steroids, but House notices his little finger twitching and decides that he must be wrong and he does not have JRA. The team suggests Kenny may just be nervous about the operation. Dr. 13 suggests Lyme Disease but House points out that Kenny has no rash. Amber suggests Rheumatic Fever. Everyone else thinks that House was correct with the JRA and the steroids have it under control. The pacing wire is successfully removed and Kenny proceeds to surgery. Dr. 13 hangs around, concerned that House is right and something besides JRA is wrong. Looking closely, she realizes that Kenny does have a rash, it is just hidden by his deformity and hair. Shaving his hair reveals the classic erythema migrans rash of Lyme Disease.

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The candidates (those that talked this week, anyway), all came up with some pretty good possible diagnoses. House, on the other hand, just seemed to randomly throw out diagnoses with little logic behind them

Lyme Disease seemed quite a stretch to me. You’ll notice they were quite vague about the time course because Kenny was exhibiting symptoms of both acute and chronic Lyme disease simultaneously. Only 60-80% of people with Lyme have the classic rash — so not finding it does not mean it can’t be Lyme Disease (but finding it almost guarantees it is). They never even mentioned ticks once.

Performing a lumbar puncture on someone with increased intracranial pressure can be very dangerous. The sudden release of pressure from the LP can lead part of the brainstem to herniate downwards, killing the patient or rendering them comatose. Getting a CT scan first is always a good idea (and admittedly there’s no suggestion that Taub would not have gotten a CT before doing the LP).

House’s reaction to the increased ICP was a little strange: it’s not an increased ICP, it’s not an increased ICP, oh, of course there’s an increased ICP but he’s always had it so it doesn’t matter. Why not just tell Taub that at the beginning and be done with it?

No joint pain in either JRA or Lyme Disease?

Did Kenny have bloody cough — as his symptoms suggested to me — or was it gastrointestinal bleeding? The differential focused entirely on the GI aspect, ignoring the pulmonary possibilities.

I can (almost) accept the Young Guns or candidates performing x-rays and CT scans, but not electrophysiology studies. They are very complex, and can be quite dangerous (one of my patients had one 2 weeks ago and his heart stopped twice during the test requiring defibrillation). It takes specialty training beyond regular cardiology to get certified, and no plastic surgeon is going to have those credentials.

Acanthosis nigricans looks nothing like Erythema Migrans and there’s no way you’d ever confuse the two. Acanthosis doesn’t show up on the face like that, either.

Was Foreman in the bathroom for the entire case? Nope, he was there, just so bland I forgot him.

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The medical mystery just wasn’t that compelling this week and earns a mere C. The solution was a stretch, and House ruled it out earlier when he should have known better, so another C. The medicine overall was only average at best — the diagnoses were good, but then dismissed with little logic for House’s pet diagnoses. This also earns a C, for a medicine hat trick. The soap opera was mostly forgettable. Dr. Terzi seemed like an intriguing character last week, but you couldn’t have told that this week. Cuddy was mostly toothless. The spotlight on Dr Taub had promise, but neglected too many of the other more interesting candidates. The House/Wilson banter nearly salvaged the soap opera and brought it up to a B-.

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Tags: television medicine house lyme disease intracranial pressure jra ventricular fibrillation

With all the characters with shrinking powers in comic books, it was only a matter of time before they started shrinking small enough to enter someone’s brain. Most of the time, the miniaturized character enters the brain to cause damage, but sometimes it is done to heal. While most common in the comics, this concept can also be seen in movies (Fantastic Voyage) and television (The Simpsons in their spoof of Fantastic Voyage, Futurama, Astroboy).

Once the shrunken character enters the brain, there are four basic “Styles of Attack”:

1. Crude and Deadly
This style occurs when a miniaturized character blunders haphazardly through the brain itself, doing as much damage as possible along the way. This is best exemplified by Jean Loring’s murder of Sue Dibney during Identity Crisis.
A more recent example had Micromax take out a leader of the Jihad in a similar manner in Marvel Comics Presents #1 (see the image below — that’s Micromax climbing out the ear; I’m not sure what that line is in the background – heart monitor? brain waves? biothythms?). Symptoms he caused included headache and seizure as well as the ubiquitous nose and ear bleeding (and death).

2. Surgical Precision
This style is most often utilized in a curative manner rather than as a weapon. The best example is actually a movie, not a comic book. In Fantastic Voyage, five adventurers and their submarine are shrunken so that they can remove a clot in a Soviet defector’s brain. A good comic book example would be Micronauts #30, where Acroyear, Bug, and Marionette are miniaturized and enter Commander Rann’s brain to cure his coma. They battle and defeat Nightmare and are able to physically unlock hidden areas of the commander’s brain.
Conceivably, precise strikes by a tiny character could also be used to damage specific parts of an enemy’s brain…but I can’t recall any good examples of this.

3. Vague but Effective
This is the most common style. A menacing villain looms up behind the heroes, ready to strike. Suddenly, they collapse in a heap and the Atom/Shrinking Violet/other-tiny-character jumps out of their ear. It’s never explained exactly what they did inside the villain’s brain (Squeezed the blood supply? Caused a seizure? Kicked something important?) — but it sure knocks them out quickly.

4. Haney-style
In the destined-to-be-classic Brave and the Bold #115 (written by Bob Haney, art by Jim Aparo), Batman is electrocuted and rendered brain dead but the Atom is able to enter his brain through the ear and control Batman like a puppet. Sure, it makes no sense anatomically, but then, Haney written titles always followed their own unique science. The Atom also manages somehow to kick-start Batman’s brain again after capturing his murderer and saving the day.

Other Comic Book Diagnoses:
Frozen Solid
Brains! Brains!
Hypertrichosis
Xenografting
De-Aging

Tags: comics medicine brain identity crisis micromax fantastic voyage micronauts atom batman baob haney

New Warriors #5 “Defiant, part 5”
Kevin Grevioux, writer
Paco Medina, penciler

Just to prove I’m not always negative, I’m going to take a moment to highlight a comic that has a well written medical scene.

After blunt force head trauma, a concussion is the most common type of head injury. Concussions are diffuse injuries and affect the entire brain. (for a longer discussion, check out my review of Stormwatch PHD #11).

More serious — and thankfully less common — injuries following head trauma are the hematomas and hemorrhages — bleeding on (or around) the brain. Intracerebral hemorrhages, or bleeding within the tissue of the brain, can occur after blunt trauma, but are not as common as bleeding just outside the brain. Subdural hematomas are the most common. These occur when there is bleeding and a collection of blood between the dura (the tough membrane that protects the brain) and the arachnoid — the middle layer of the meninges (the membranes that surround and protect the brain). The hematoma causes increased pressure within the skull which can be life threatening, as well as direct damage to the areas of the brain underlying the hematoma. An epidural hematoma is similar, except the bleeding occurs between the dura and the skull itself.

Hematomas that are small can be monitored closely and should resolve on their own. Larger hematomas, especially those causing life threatening symptoms, require surgical intervention. The blood needs to be drained and — if possible — the source of the bleed found and stopped. This usually requires a burr hole or a craniotomy.

Of course, I do have a couple of small nitpicks, all regarding the art. Overall — as always — Medina does a good job with both the action scenes and the quieter moments. However:
If our patient just had cranial surgery, she should have her head bandaged, not in a surgical cap.
The art suggests that her burns were most likely to her back, in which case having her lie on her back like that just seems cruel (of course, we don’t know how extensive the burns are, they could be small and inconsequential).
The heart tracing bears little resemblance to an actual heart tracing, even in a case of cardiac arrest (the one on the cover is fine, though).

*For spolierific reasons, I’m not going to name the character, though she is shown injured on the cover.

Tags: comics medicine new warriors concussion subdural hematoma epidural hematoma kevin grevioux paco medina

Fantastic Four #549 “Reconstruction Chapter 6: So I guess You’re Saying the Honeymoon’s Over”
Dwayne McDuffie
Paul Pelletier

In a memorable and clever scene from Fantastic Four #549, Sue Richards puts the fear of God into the Wizard by threatening his life. More specifically, she threatens to use her powers to block his coronary arteries causing a massive heart attack. (Now is Sue making a real threat, or just bluffing? I leave that up to you).

Click here or the image on the right for the full scene.

♥  This is a good example of what I like to call “medicine on the attack”: characters who have enough knowledge of anatomy and physiology to cause significant damage when using their powers in a certain way. Iron Man and Battalion are two others who have made use of similar tactics. The heart always seems to be the target, but that makes sense because everyone knows where to find it, how important it is, and roughly how it works. The same can’t be said for most of the other organs (“Be careful Mole Man, or I shall crush your spleen!” just doesn’t carry the same weight) . I’ve also noticed it’s the “heroes” who are the ones making this type of attack.

♥  Despite what the Wizard says, it’s technically not a thrombosis because that refers specifically to a blood clot. You can’t fault him much for the wrong answer because no one has coined a medical term to describe an invisible forcefield blocking an artery.

♥  Sue’s plan is a little overkill. Blocking the three main coronary arteries (left anterior descending, circumflex coronary artery, right coronary artery) is more than enough to cause a fatal heart attack. Knocking out the left anterior descending alone should do the trick — it’s called the widow maker for a reason.

♥ The art looks a little misleading at first. In real life, the heart and lungs aren’t just sitting there free in the chest — they are both covered by tough protective membranes (the pericardium for the heart, and the pleura for the lungs). There’s a simple explanation though: Sue must have turned them invisible, just as she turned the Wizard’s skin and ribcage invisible. Overall, Pelletier’s command of thoracic anatomy is quite impressive.

♥ Personally, I think an even better tactic against the Wizard would be to threaten him with a stroke. Sure, threatening him with a heart attack puts his life at risk, but threaten him with a stroke and it’s his brain — his raison d’etre — that’s on the line. Just replace Sue’s comment about the coronary arteries with this line: “A man as smart as you surely knows what happens if I used a force field to close your carotid arteries.” He’d probably die of fright right there on the spot.

Tags: comics medicine fantastic four sue richards wizard heart attack

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

This example of the psychic nosebleed (and mouth- and earbleed) comes from about halfway through the manga series Akira. Tetsuo is experimenting with drugs that increase psychic powers and has given it to three “volunteers.” Two die almost immediately (an exploding brain will do that two you), but the third survives (but is probably permanently brain damaged).

Scenes are by Katsuhrio Otomo and can be found in Akira #17 (the 1990 version published by Marvel’s Epic Comics imprint )

All previous Psychic Nosebleed Zen posts

Tags: comics medicine manga akira katsuhiro otomo

Detective Comics #833, 834 “Trust”
Paul Dini, writer
Don Kramer, penciler

By request of David, a look at the drowning scene in this recent storyline from Detective Comics.

The pathophysiology of drowning is actually fairly complex, but here’s a quick look at the basics: intake of fluid into the lungs disrupts the air/lung interface, preventing the diffusion of oxygen (in) and carbon dioxide (out). This leads to hypoxemia (low oxygen levels) and respiratory acidosis. These in turn lead to other significant problems including asphyxiation, cardiac arrest, and brain damage which in turn lead to death.

In an attempt to stave off drowning, an individual can hold their breath, but eventually the urge to breathe will overcome their resolve and they’ll end up taking a breath of water — or whatever medium they happen to be in at the time.

The exact anatomical mechanism behind breath holding is not clear. The glottis snaps shut, sealing off the airways. There is also thought to be involvement of some of the respiratory muscles, including the diaphragm, preventing breathing.

In the story, Zatanna has been shot in the neck1 — apparently disrupting her trachea/vocal cords so she can’t speak — making casting spells difficult2. She is then dumped tank of water which is subsequently locked shut. After some repartee with the villain and an escape from a classic electrical trap, Batman frees Zatanna from the trap. He finds she has managed to heal herself of her neck injury, but has fallen unconscious in the tank.

Because of Zatanna’s injury, it’s unlikely her glottis can close tightly enough to keep water out of her lungs even when she holds her breath. The average adult drowning victim has just 4 ml of water in their lungs — Zatanna will have much more than that. This means she’ll have an extremely difficult time taking a breath and will likely drown even if she manages to escape the water. The water leaking into her lungs should not affect her ability to hold her breath; it will only affect her when she has to take a breath.

How long can Zatanna hold her breath? The world record for humans³ is a little over 9 minutes (9 minutes and 8 seconds, to be precise). Of course, that is someone who has been specially trained and has had time to prepare beforehand. By contrast, Zatanna has been caught by surprise, shot, and dumped in a tank of water — that definitely puts her at a disadvantage. Still, I think she would be able to hold her breath for at least 30- 60 seconds, maybe even longer, which should be enough time to write “EM LEAH” on the ceiling of the tank⁴. It looks like it takes Batman another minute or two to rescue her. She’s unconscious and hypoxemic, but not dead. If Batman can restore her breathing in time, she should not suffer any permanent problems.

To me, that’s the real issue: can Batman restore her breathing in time? Medically, Zatanna is going need hospital evaluation after her near-drowning because of the amount of water she inhaled. Some Bat-CPR and a watchful eye at Wayne Manor probably isn’t going to be sufficient. She needs 100% oxygen and will most likely require intubation and admission to the intensive care unit. I don’t think she’ll be ready for round two for at best a few days, probably longer.

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Notes:
1. That’s an incredibly skilled shot to take off the cuff like that. I can believe Deadshot could pull it off, but the Joker?
2. Has an actual vocal component always been required by Zatanna to cast her spells? She can’t just mouth the words?
3. And remember that Zatanna is only half human.
4. The tank is full of sloshing water, yet her letters written in blood don’t get washed away? I find this more unbelievable than Zatanna being able to hold her breath as long as she did.

It’s the most shocking House yet! Not really — I just thought I’d mimic the ads that play every week (at least on the St Louis affiliate). How can every week be the most shocking?

In reality it was just another so-so episode. The mystery was good, but House’s final deductive leap was a little too unbelievable. The medicine was just OK, but the soap opera parts were much better than the past few weeks.

Addie, a nineteen year old college sophomore is sparring in a karate match when she suddenly begins spitting up blood. In the ER, a bronchoscopy was performed (looking down her lungs with a fiber optic scope). An Upper and Lower GI were also performed, as well as multiple blood tests. All were normal.

Chase suggests that Addie might have a hyperdynamic heart — one that’s pushing more blood than it should, causing extra blood to leak into the lungs causing a bloody cough (this is quite a stretch). A stress echocardiogram is performed but is normal. Chase notices that Addie has goosebumps, yet denies feeling cold or scared. Foreman states it might be a hypothalamic injury while House believes it is a sign of infection. He orders blood cultures, a lung biopsy, and starts her on antibiotics. She later develops diarrhea, but this is blamed on the antibiotics and never mentioned again.

Addie suffers respiratory arrest and requires intubation. She has a pleural effusion (a fluid build-up around the lungs) which is drained by thoracentesis. The effusion is transudative (this has to do with how much protein is in the fluid) which usually represents liver failure or heart failure. These seem unlikely since her echocardiogram and liver function tests were normal (though kidney failure can also cause a transudate — just foreshadowing here). House spots a trace amount of blood in the fluid and believes that it confirms his infection hypothesis, while Cameron points out that blood in the fluid could also represent a cancer. House next orders an arteriogram which is also normal. He is now convinced that the patient has Complement H Deficiency, a deficiency he claims is so rare that there’s no way to test for it. And it’s untreatable and fatal. A macular biopsy is performed but is negative (the macula is the most sensitive part of the retina; there seems to be a connection between age-related macular degeneration and certain types of Complement H abnormalities.). This doesn’t confirm House’s diagnosis, but it doesn’t disprove it either, so he considers it a good sign. The rest of the team point out that her symptoms could be caused by a brain clot or tumor. Cameron states that Addie was bleeding, so she can’t have a clotting disorder (Cameron’s never heard of DIC, apparently), so it must be a tumor. House still maintains Addie’s symptoms are due to the Complement H Deficiency and infection. An MRI is obtained, but shows no clots, tumors, or signs of infection. While in the MRI tube, Addie complains of a severe headache. The team pulls her out and discovers that a chunk of her scalp has become necrotic and started to bleed out. House believes this fits with his infection theory, but Chase states that it could be an autoimmune disease. He wants to put her on steroids. House states that if Chase is wrong and House is right, then Addie will likely have a heart attack as soon as the steroids are started and die. He allows Chase can give the steroids, but only with Cameron standing by with defibrillator paddles. The steroids are given and no heart attack results.

Later that night, House is woken by the news that Addie has developed severe kidney failure due to Hemolytic Uremic Syndrome (HUS) and is on dialysis. House points out that HUS is often caused by an infection (and is more common in people with certain Complement H deficiencies), then trots out the false dichotomy of the episode: he states that since Chase was wrong, House must be right and therefore Addie must have Complement H Deficiency. This means that she will soon die of her disease. She slips into ventricular fibrillation, but Foreman is able to revive her. House takes this as the final sign that he’s right and goes to talk to Addie and her parents. Shortly after talking with them he has a conversation with Wilson, and it the middle of it realizes that Addie does not have Complement H deficiency. Instead, Addie is depressed and has a death wish. She tried to kill herself with drain cleaner, but instead of drinking it, she placed it in a gel cap and swallowed it. This way, it didn’t start to dissolve her GI tract until it hit her intestine where it ate a hole (leading to spitting up blood). Scar tissue covered the hole, so the bleeding stopped, but the damage caused an artery and vein to grow together and this mixing of venous and arterial blood is seeding infections throughout her body. By repairing the blood vessel, Addie will be able to recover physically, but still has a ways to go mentally.

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Not that the House writers have ever made it a completely fair mystery, but this week they definitely weren’t playing fair with the clues. Each episode usually makes a big deal of searching the patient’s house, but it wasn’t shown at all this week (though Cameron was ordered to) — and it would have likely turned up some positives (empty gel caps and drain cleaner, for instance). A patient has a likely gastrointestinal bleed, yet no EGD or colonoscopy were performed — because one of them should have showed the healing bleed, or at least the scar tissue (and according to the links in the narrative, the GI series should have shown scar tissue as well). Addie has all these infections, yet her blood cultures are all negative?

Otherwise, I’m not clear on the use of the arteriogram to look for infection, nor am I entirely certain why her “head exploded.” And why would steroids suddenly cause a heart attack? From what I’ve been able to ascertain, it is possible to test for Complement H deficiency (molecularly, functionally, and genetically). It may not be a common test, but since when has that stopped House?

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I give the medical mystery a B+, because it was intriguing. The final solution I give a C. It was clever, but the way House was able to deduce exactly what happened, down to the anatomic level, instantly and without any lead up I found too unbelievable, even for House. Yet again, the medicine was blah. Not completely horrible, but not particularly good either. This is Grey’s Anatomy level medicine — it may be fine for that show, but it earns a weak C here. The soap opera was quite enjoyable this episode, particularly the whole Wilson on speed scene. I give it an A
The previous House review
A list of all prior House reviews

Tags: television medicine house complement h hemolytic uremic syndrome suicide

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

New Excalibur #17 “Fallen Friend, part 2”
Chris Claremont, writer
Scot Eaton, penciler

As the issue starts, Talia (Nocture) can barely move her right limbs. In addition, she is having trouble remembering her teammate’s names, as well as difficulty speaking and understanding what others are saying.

(I think the listening and speaking difficulties are supposed to be aphasia — damage to language center in the brain– but it wasn’t made entirely clear by the script. She could also be having some dysarthria — trouble controlling the speaking muscles.)

Within the first couple of days after the stroke, Talia’s memory and communication problems have cleared up, but she is still struggling with right hemiparesis (weakness of the muscles of her right side) at the end of the issue.

Medically, this is a good representation. As the issue begins, Talia has two things going wrong within the brain. The first is the damage from the stroke itself. This damage is responsible for the right hemiparesis. With time and aggressive therapy and rehabilitation, these symptoms can sometimes improve. Frankly, complete recovery from a stroke is rare and the majority of patients who suffer strokes will continue to show symptoms for the rest of their life.

Talia also has swelling and inflammation of the brain. This can be seen after some strokes, particularly hemorrhagic strokes (which is what I speculated she suffered). It is this inflammation that is causing her aphasia and memory problems. As the swelling and inflammation resolve — usually in the first couple of days after the stroke — those problems should improve.

What strikes me the most with this storyline is the clear parallel between Talia and the writer, Chris Claremont. Last year he suffered a serious heart problem that required significant rest and rehabilitation. And now in his first story back, the focus is a character who suffers a debilitating cardiovascular disease that also requires extensive rest and rehabilitation. While Claremont’s was a heart problem and Talia suffered a stroke, they are related diseases with similar causes. I don’t think it’s a wish fulfillment or a Mary Sue situation, but just Claremont bringing some of his own recent experiences into the comic. It will be interesting to see how the storyline progresses (and if it is ever explained why Talia suffered the stroke).

Tags: comics medicine excalibur chris claremont stroke aphasia hemiparesis

A request has been made for me to review New Excalibur #17 which details Talia’s recovery from her stroke. First, however, I’d like to take a look at New Excalibur #16, which features the stroke itself.

New Excalibur #16 “Fallen Friend, part 1”
Chris Claremont, writer
Scot Eaton, penciler

In Excalibur #16, Talia (Nocturne) suddenly suffers an apparent stroke. Visiting Dazzler in the hospital, she suffers a sudden loss of coordination, headache, numbness of both arms and legs, and then unconsciousness.

Generally speaking, there are two types of strokes. The most common (80%) is an ischemic stroke, where blood flow to one of the blood vessels in the brain is blocked by a clot. This prevents blood from getting to part of the brain, and this part will almost immediately stop functioning, and will die if blood flow is not restored quickly. The leading treatment for ischemic strokes are clot-busting drugs (also known as thrombolytics), but they have to be given within 3 hours of the onset of symptoms. Blood thinners may be used to prevent a subsequent stroke,

The second type of stroke is a hemorrhagic stroke, where one of the blood vessels in the brain starts to leak or bleed. This causes damage in several ways. First, the brain tissue beyond the bleed is denied its blood supply and can die, just like in an ischemic stroke. Second, blood is irritating to the brain tissue which causes swelling and inflammation. Third, if enough bleeding occurs, it can raise the intracranial pressure which can restrict blood flow to the entire brain. The treatment of a hemorrhagic stroke should come as no surprise: stop the bleeding. This may require surgery. Additionally, if a large amount of blood has collected, it may need to be surgically drained. Since the treatment for an ischemic stroke, clot-busters and blood thinners, will make a hemorrhagic stroke worse, you need to be sure what type of stroke has occurred before treatment is started.

So far, it’s not clear which type of stroke Talia suffered. Given her headache and loss of consciousness, a hemorrhagic stroke seems more likely as these are symptoms of increased intracranial pressure. However, no mention has been made of any surgery or neurosurgical evaluation. On the other hand, no mention has been made of thrombolytics or blood thinners either, though when Sage explains what a stroke is to Pete Wisdom, she only mentions ischemic strokes. Frankly, I’d be surprised if we ever find out for sure what type of stroke she had.

Doctor: Set up a fell series of x-rays — chest and skull. MRI’s as well — someone find out if we have to worry about her super-powers? And check with her teammates, she’s got different hand and feet structures, blue skin and weird eyes — are there any internal differences we need to know about?

I’m not certain why the x-rays were ordered. Talia was showing neurological symptoms and then she lost consciousness. The differential diagnosis would include stroke, seizure, hemorrhage, drugs, infection, or metabolic disorders — none of which show up on x-ray*. There is only a limited time window to treat a stroke, particularly an ischemic stroke, so there is no need to waste time getting unnecessary x-rays. An MRI makes sense because it has a good study for showing a stoke, either ischemic or hemorrhagic.

It’s nice to see a doctor taking super-powers into account , one would presume both for his sake as well as the patient’s. It’s what I would expect to see in a comic book hospital. Of course, in a comic book universe, we should probably add “telepathic disorder” to the differential — but then again, she doesn’t have a nosebleed, so maybe not.

Tomorrow: The requested review of New Excalibur #17 (plus I believe #18 is available in stores UPDATE: Oops. Not yet)

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*to be fair, “trauma” would also be on the differential – and that would seem a likely possibility in a superhero who had recently been in a fight — and while trauma should show up on x-ray, it would show up on the MRI as well, so there’s no reason to waste time getting an x-ray. (Plus the x-ray wouldn’t give a good view of the brain itself, just the skull. ) Just go straight to the MRI (or CT).

Tags: comics medicine excalibur chris claremont stroke

In this week’s episode of House, the mystery is good, but the medical treatment is not. There are some good character moments, but this doesn’t stop the Tritter storyline from limping to a weak ending. Spoilers follow!

Derek, a firefighter, becomes short of breath and disoriented while at the scene of a fire. He tells his partner Amy that he is feeling chills. He is brought to the hospital and admitted to House’s service. Cameron notes that he has a fluctuating temperature as well as skin grafts over half his body from bad third-degree burns suffered on the job a year ago. She also discovers that he has had several episodes of disorientation in the past few weeks. Cameron reports that Derek’s tests for hepatitis C, HIV, TB (tuberculosis), Lyme disease are all negative, as is his drug screen. The EKG is said to show an “arrhythmia” (an abnormal rhythm) but House blows it off. Foreman suggests a hypothalamic tumor, while the other doctors are suspicious of a hospital acquired infection — one he picked up when he had his skin graft surgery and which has smoldered since then. They are concerned about MRSA (methacillin-resistant Staph. aureus), a particularly nasty germ.

Because of concern about MRSA, Derek is placed in isolation. He casually reveals to Cameron that everything looks blue. Foreman mentions heavy metal poisoning as a cause of this, particularly thallium. House suspects the patient has “male menopause” (low testosterone, elevated estrogen levels) brought about by burns he has suffered to his genitals. Viagra is known to cause blue color shifts, and House believes he is taking Viagra to make up for the effects of the low testosterone. The next time we see Derek, he is out of isolation (the MRSA tests came back negative) and he is receiving hormone therapy (apparently his levels were low). He suddenly starts screaming that the hormones are causing pain, then he lashes out and starts throttling Cameron. Foreman sedates him with some Lorazepam (brand name: Ativan).

The team tests, but Derek is not allergic to the hormones and they were not contaminated. Additionally, there is no evidence of a pulmonary embolism and his EKG is normal. Foreman, true to form, suspects a neurological cause, either a frontal lobe tumor or meningitis. However, a CT scan and lumbar puncture are normal. Other possible diagnoses mentioned include polyarteritis nodosa (a rare disease caused by inflammation of the arteries) and Legionnaire’s disease. Chase also believes it is unusual that Derek’s drug screen is negative as he must be taking some pain medication to treat the severe pain from his skin grafts.

The Young Guns are paged to Derek’s bedside where they discover that he has become suddenly short of breath and tachycardic (rapid heart rate). His oxygen saturation is 85%. Chase notices ST elevation on the EKG and realizes that Derek is having a heart attack. Elevated cardiac enzymes confirm this diagnosis (a heart damaged by a heart attack will release certain proteins in a predictable pattern over several days. By testing for these proteins, you can discover if a patient has had a heart attack.) The team eventually realizes that the common denominator in all of Derek’s attacks is his partner Amy. It is only when she is around that he has problems. They can find no inciting agents she carries, but Cameron recognizes that Derek is in love with Amy. He explains that she is engaged to his brother and that he can never have a relationship with her. Cameron explains to the rest of the team that Derek is literally dying of a broken heart.

The team starts Derek on beta-blockers and nitroglycerin (common medications for heart attack patients) but they don’t help. The team considers antidepressants, but discards the idea because House believes their side effects will make things worse (which is quite a stretch). Chase suggests propylthiouracil (a drug that is inhibits the thyroid gland), but House feels it would be bad for the heart as well (not to mention a bizarre and incorrect use of the drug). At the end, the team decides to use EST (electroshock therapy) to cause a permanent memory loss so Derek won’t remember Amy or his brother.

The therapy seems to be successful, but in a casual conversation with Amy, Cameron discovers that she was never engaged to Derek’s brother. It turns out that Derek had false memories (I would have first thought of House’s favorite mantra –”patients lie” — rather than jump to the diagnosis of false memories). A brain MRI (now they get an MRI) shows decreased blood flow to one part of the brain. A close look at the blood flow in the spine shows a spinal meningioma (a tumor of the membrane that covers the spinal cord) that is pressing against the blood vessels supplying blood to the brain. When this tumor is removed, Derek will be good to go (well, except for that permanent memory loss).

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Medically, the two big problems this episode were the EKGs and the ECT.
In the beginning, House ignores an abnormal EKG. You never ignore an abnormal EKG — that’s just asking for trouble, and they would likely have made the diagnosis much sooner (but then the show would be too short). Then later in the episode, Derek had a normal EKG. If he truly had suffered multiple heart attacks, there’s no way he would have had a normal EKG.

The biggest problem was the EST. First, there’s no way EST would ever be used without a psychiatrist’s evaluation and consent, and no psychiatrist would jump straight to EST without attempting other therapies first. A thorough testing, evaluation, and history would reveal the false memories. EST is still used occasionally for depression, schizophrenia, and mania — but the patient is suffering from none of these. EST can certainly cause memory problems, and does cause temporary memory loss in most patients, but it is not a predictable effect and ECT is not used to purposefully block out memories.

For nitpicking, I will point out that the bacterial cultures came back surprisingly fast once again, and that Cameron needs to brush up on her isolation skills. She wasn’t dressed correctly for either contact isolation or drawing blood.

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On the non-medical side, I liked the scenes with House and Cuddy and House and Wilson — especially the ones with Cuddy; she showed some real teeth. I thought his interactions with Foreman and Chase were good, but wasn’t as impressed with the scenes with Cameron.

Legally, it seemed all wrong. I am certainly not a lawyer, but the show seemed to be confusing grand juries and actual trials. The judge said she was going to determine if there was enough evidence to try House, which suggests a grand jury (or something like that), but House pleaded “Not Guilty” before that. How can he plead if he hasn’t been brought to trial on charges yet?

And the resolution of the whole Tritter storyline? Let’s just say that it ended with a whimper and too much deus ex machina for my taste.

I did like that House had the last laugh after all.

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The medical mystery was good, so I give it a B+ and the ultimate solution was well-thought out and earns another B+. The actual medical treatment was bad, especially the EST aspect, and drags down the overall medical score to a D+. The character interaction/soap opera was good and earns an A-. Overall, I give the Tritter arc a C-.

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Tags: television medicine house mrsa electroshock therapy meningioma

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